AHA Coding Clinic® for ICD-9 - 2006 Issue 3; Ask the Editor

Hematoma Secondary to Catheter Thrombolysis

The patient previously had a right subclavian vein thrombosis, which was treated with direct catheter thrombolysis and complete resolution of the thrombus was accomplished. At that time, the patient was also diagnosed with thoracic outlet syndrome. Surgical resection of the first rib was recommended, but the patient refused. The patient was then fully anticoagulated on Lovenox and Coumadin and discharged home. After discharge, the patient noted increased swelling in the upper arm region and was readmitted for further work-up. The provider’s final diagnostic statement listed “intramuscular hematoma, complication of catheter thrombolysis, anticoagulation and thoracic outlet syndrome status post subclavian vein thrombosis.” What are the appropriate code assignments for the second admission? ...

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