Chronic venous htn w ulcer and inflammation of r low extrem

This code signifies a persistent elevation of venous pressure in the right lower extremity, not attributable to a specific underlying cause, which has led to the development of both an open sore (ulceration) and signs of infection or irritation (inflammation). It indicates a complex and advanced stage of chronic venous insufficiency affecting the right leg.

This code is appropriate when documentation clearly states chronic venous hypertension, specified as idiopathic, with evidence of both ulceration and inflammation on the patient's right lower extremity. Clinical notes should detail the presence of an open wound and inflammatory signs (e.g., erythema, warmth, swelling) in the context of long-standing venous pressure issues.

• Ensure documentation explicitly states "idiopathic" or "unspecified cause" for the venous hypertension.
• Verify that both an ulcer and inflammation are present and documented for the right lower extremity.
• Do not use this code if the venous hypertension is secondary to a known cause (e.g., deep vein thrombosis).