Postthrombotic syndrome with ulcer of right lower extremity

This code describes a chronic condition occurring after deep vein thrombosis (DVT) in the right lower extremity, characterized by persistent venous hypertension and damage to venous valves. The presence of an open sore or wound (ulcer) on the right leg is a key feature, indicating severe postthrombotic syndrome.

Use this code when documentation clearly indicates a patient has postthrombotic syndrome affecting the right lower extremity, and an active venous ulcer is present on that limb. Supporting documentation should include a history of DVT in the right leg, physical exam findings of chronic venous insufficiency, and a description of the ulcer.

• Ensure the documentation specifies "right lower extremity" and the presence of an "ulcer" to differentiate from other laterality or complications.
• Do not use this code for postthrombotic syndrome without an ulcer, or for ulcers due to other etiologies (e.g., arterial, diabetic).
• Consider sequencing this code after any acute DVT if the postthrombotic syndrome is a direct sequela being treated.