Hypercoagulable states are often omitted from provider documentation. If systemic anticoagulation is used to treat acute clots or prevent new clot formation, a hypercoagulable state should be documented. Hypercoagulable state is a comorbidity/complication (CC) and helps reflect the severity of illness in your patient.
Some conditions predispose patients to clotting and should be documented as “secondary hypercoagulable states” when acute DVTs/PEs are caused by those conditions.
| Primary Hypercoagulable States (CC) | Secondary Hypercoagulable States (CC) |
| Factor V Leiden | Active cancer |
| Protein C deficiency | Myeloproliferative disorders |
| Protein S deficiency | HIT |
| AT3 deficiency | Nephrotic syndrome |
| Prothrombin Gene Mutation | Oral contraceptives |
| Sickle cell disease/crisis | |
| Pregnancy/Postpartum | |
| DIC | |
| Estrogen receptor modulators (tamoxifen, raloxifene) | |
| Antiphospholipid antibodies (Anticardiolipin and Lupus anticoagulant) | |
| TTP |
Remember to use “possible” “probable” or “still to be ruled out.”
Download the complete tip, Hypercoagulable State.