H66.91 - Otitis media, unspecified, right ear

Clinical Definition

Deep vein thrombosis (DVT) is a serious condition where blood clots form in deep veins, most commonly in the legs. The clot can partially or completely block blood flow through the vein, causing swelling, pain, and potential complications if left untreated.

Documentation Requirements

• Laterality

  • Right

  • Left

  • Bilateral

• Specific Vein Location

  • Lower extremity

  • Upper extremity

  • Other specified vein

• Chronicity

  • Acute

  • Chronic

  • Acute-on-chronic

• Associated Conditions

  • With/without pulmonary embolism

  • Post-thrombotic syndrome

• Cause/Risk Factors

  • Post-procedural

  • Pregnancy-related

  • Cancer-associated

  • Immobility-related

Common Synonyms

• Blood clot in leg/arm

• Venous thrombosis

• Blood clot in deep vein

• Peripheral thrombosis

Coding Conflicts

• Excludes1:

  • Superficial thrombophlebitis

  • Portal vein thrombosis

• Excludes2:

  • Cerebral venous thrombosis

  • Chronic embolism and thrombosis

Scribing.io Automation

The AI scribe automatically detects:

• Location descriptors ("left leg," "right upper extremity")

• Timing words ("acute," "chronic")

• Risk factor mentions ("post-surgery," "cancer-related")

• Associated complications ("with PE")

• Treatment plans ("anticoagulation initiated")

When dictating, use clear anatomical terms and specify chronicity for optimal documentation capture.