Hypercoagulable State

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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.