Postthrombotic syndrome with ulcer of unsp lower extremity

This code describes a chronic venous insufficiency resulting from a previous deep vein thrombosis (DVT), specifically presenting with an ulcer on a lower extremity where the laterality is not specified. The postthrombotic syndrome (PTS) indicates persistent symptoms like pain, edema, and skin changes, with the ulcer being a severe manifestation.

Use this code when documentation confirms a diagnosis of postthrombotic syndrome with an associated venous ulcer, and the medical record does not specify whether the ulcer is on the right or left lower extremity. This code is appropriate when the physician explicitly links the ulcer to a prior DVT.

• Ensure documentation clearly states "postthrombotic syndrome" and the presence of a "venous ulcer."
• If laterality (right or left) of the ulcer is documented, use the more specific codes I87.011 (right) or I87.012 (left).
• Code any associated DVT (acute or chronic) separately if still present and being treated.