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Deep Vein Thrombosis G022

Last amended 
18 March 2021
Current RMA Instruments
Reasonable Hypothesis SOP
35 of 2021
Balance of Probabilities SOP
36 of 2021
Changes from previous Instruments

SOP Bulletin 219

ICD Coding
  • ICD-9-CM Codes: 451.1,451.81,451.83,451.89,453.2,453.8
  • ICD-10-AM Codes: I80.1, I80.2, I80.8, I82.2, I82.8
Brief description

A deep vein thrombosis (DVT) is the formation of a blood clot (thrombus) within a deep vein, usually in the leg.  Pulmonary thromboembolism, caused by a clot that detaches and travels to the lungs, is covered by a separate SOP.

A DVT is an episodic condition.  If there are separate episodes of DVT they may warrant being diagnosed and determined separately.

Confirming the diagnosis

The condition may be suspected on clinical grounds.  Confirmation requires imaging, usually in the form of doppler ultrasound.  A D-dimer (blood) test may be used to assist with excluding the diagnosis, and make an ultrasound unnecessary.

The relevant medical specialist is a haematologist or general physician.

Additional diagnoses covered by SOP
  • Deep venous thrombosis
Conditions excluded from SOP
  • Arterial thrombosis
  • Retinal vein thrombosis* - retinal vascular occlusive disease SOP
  • Non-thrombotic embolism of the venous system#
  • Pulmonary thromboembolism*
  • Superficial thrombophlebitis / superficial venous thrombosis of the upper or lower limbs#
  • Thrombosis of cerebral, pulmonary, hepatic, renal, portal or mesenteric veins#
  • Varicose veins*

* another SOP applies

#  non-SOP condition

Clinical onset

The condition may be asymptomatic, or present with non-specific features inluding unilateral swelling, pain, warmth, erythema or engorged superficial veins in a leg.  There is often an event (e.g. surgery, trauma, a period of immobilisation) that can help to pinpoint the onset.  The condition may not be suspected until pulmonary thromboembolism has developed.  If there is a past history of DVT and a new episode occurs, it may be appropriate to regard the new episode as a separate condition, with a new clinical onset.

Clinical worsening

The only SOP worsening factor is for inability to obtain appropriate clinical management.  Appropriate management is directed at preventing progression of thrombosis and the development of thromboembolism, and includes anticoagulant therapy, when indicated.