Chronic venous htn w ulcer and inflam of unsp low extrm

This code signifies a persistent elevation of venous pressure in an unspecified lower extremity, not attributable to a known underlying cause (idiopathic), which has led to the development of both an open sore (ulcer) and signs of inflammation (e.g., redness, swelling, warmth). It describes a severe manifestation of chronic venous insufficiency where the skin integrity is compromised and an inflammatory response is present.

Apply this code when documentation clearly indicates chronic venous hypertension of an unknown origin affecting a lower limb, accompanied by both an active ulcer and inflammatory changes. This diagnosis is supported by physician notes detailing the presence of a venous stasis ulcer, signs of inflammation (e.g., cellulitis, dermatitis), and the chronic nature of the venous hypertension without a specified secondary cause.

• Ensure documentation specifies "idiopathic" or "primary" venous hypertension if no underlying cause is identified.
• Verify the presence of both an ulcer and inflammation; if only one is present, a different code may be more appropriate.
• This code is for an unspecified lower extremity; if the laterality (left or right) is documented, a more specific code should be used.