AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2025 Issue 2; Ask the Editor
Factor V Leiden
A patient with a diagnosis of factor V Leiden presented to the office for a follow-up encounter and the provider documented that the patient’s Coumadin was adjusted. When referencing “mutation, factor V Leiden” in the Alphabetic Index, the coding professional arrives at code D68.51, Activated protein C resistance. When referencing “deficiency, factor, V” the coding professional arrives at code D68.2, Hereditary deficiency of other clotting factors. There is no default code for “Factor V Leiden” without referencing the terms “mutation” or “deficiency.” What is the appropriate code assignment when only factor V Leiden is documented by the provider? ...
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Article Overview
This short coding guidance article is for ICD-10-CM users who need help interpreting documentation related to Factor V Leiden in a follow-up office setting. It discusses the indexing terms that may be encountered and why the documentation must be reviewed carefully when the provider’s wording is limited.
Why This Topic Matters
Accurate interpretation of the documented terminology affects diagnosis coding for inherited clotting-related conditions and supports consistent record abstraction in outpatient follow-up care.
What You Will Learn
- How Factor V Leiden is discussed in ICD-10-CM indexing terms
- Why the exact wording in provider documentation matters for diagnosis selection
- How a follow-up office encounter context can affect the coding question being raised
- Why supplemental review of indexing terminology may be needed when documentation is limited
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Billing and reimbursement professionals
Codes Discussed
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