Postthrom syndrome w ulcer and inflam of unsp low extrm

This code signifies a chronic venous insufficiency resulting from a previous deep vein thrombosis (DVT), specifically presenting with both an ulcer and inflammation in an unspecified lower extremity. The postthrombotic syndrome (PTS) has progressed to involve skin breakdown and an inflammatory response.

Apply this code when documentation clearly indicates a patient has a history of DVT and is currently experiencing a venous ulcer alongside signs of inflammation (e.g., erythema, warmth, swelling) in a lower limb, without specification of laterality. This code requires explicit mention of both ulceration and inflammation as manifestations of PTS.

• Ensure documentation specifies both "ulcer" and "inflammation" as components of the postthrombotic syndrome.
• Avoid using this code if only an ulcer or only inflammation is present; separate codes exist for those scenarios.
• If laterality (left or right) of the affected lower extremity is documented, a more specific code should be selected.