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|
|Estrogen receptor modulators (tamoxifen, raloxifene)|
|Antiphospholipid antibodies (Anticardiolipin and Lupus anticoagulant)|
Remember to use “possible” “probable” or “still to be ruled out.”
Download the complete tip, Hypercoagulable State.