Name of the Condition

• Varicose Veins of Right Lower Extremity with Ulcer, Other Part of Lower Leg
• Medical term: Chronic venous insufficiency with ulceration

Summary

• This condition involves abnormally enlarged veins in the right lower leg, specifically accompanied by an ulcer. The veins are swollen and weakened, causing blood to pool and sometimes resulting in breaks in the skin, or ulcers.

Causes

• Caused by weakened or damaged valves in the veins, leading to improper blood flow.
• Prolonged standing or sitting, obesity, pregnancy, and hormonal changes can contribute.

Risk Factors

• Aging, family history of varicose veins, female gender, obesity, pregnancy, and a sedentary lifestyle increase risk.

Symptoms

• Swollen, twisted veins visible under the skin.
• Pain, heaviness, or aching in the affected leg.
• Development of skin ulcers, particularly near the ankle.
• Itching around the veins.

Diagnosis

• Physical examination and patient history.
• Ultrasound to assess vein function and blood flow.
• Venography or other imaging if needed.

Treatment Options

• Compression stockings to improve blood flow.
• Medications like pain relievers and anti-inflammatory drugs.
• Sclerotherapy or laser treatment to close varicose veins.
• Surgical options such as vein stripping or ligation for severe cases.
• Wound care for ulcers.

Prognosis and Follow-Up

• Management with lifestyle changes and treatment can improve quality of life.
• Regular monitoring to prevent complications like ulcers or deep vein thrombosis.

Complications

• Severe pain and discomfort.
• Skin ulcers can become infected.
• Increased risk of deep vein thrombosis (DVT).

Lifestyle & Prevention

• Maintain a healthy weight, exercise regularly, and elevate legs to improve circulation.
• Avoid prolonged standing or sitting.
• Wearing compression stockings as recommended.

When to Seek Professional Help

• Immediate attention required for severe leg pain, open sores or ulcers, and skin changes.
• Seek medical advice if symptoms don't improve with basic management.

Additional Resources

• American Vein and Lymphatic Society (https://www.myavls.org)
• Society for Vascular Surgery (https://vascular.org)

Tips for Medical Coders

• Ensure accurate documentation of which leg is affected and presence of ulcer.
• Avoid confusion with similar ICD codes that do not specify ulceration.
• Confirm correct code when additional conditions or complications are present.