Sunday, August 28, 2016

5 Facts Everyone Needs to Know About Factor V Leiden

Here are 5 facts that everyone needs to know regarding a common condition that predisposes to potentially deadly clot formation, either deep vein thrombosis (leg clots) or pulmonary embolism (lung clots).

1. Factor V Leiden (FVL) is a mutated Factor V, one of the factors essential to form a clot. The mutated factor, once activated, is more difficult to clear by the body, being this the reason why people with this mutation may form clots easier than people who do not have it.

2. About 5% of Caucasians have at least one copy of FVL (of 2 possible from mother and father). It is rare in other ethnicities. 0.02% of Caucasians have the two mutated copies.

3. A person with one copy of FVL has a 4 to 8 times increased chanced of developing a clot. A person with 2 copies has up to 80 times increased risk of developing a clot. Someone with a normal Factor V has a chance of developing a clot of 1 in 1000 in 1 year. This means that an individual with one copy of FVL can have a 4-8 in 1000 (0.4-0.8%) chances to develop a clot in a year and an individual with the 2 copies can have a risk of 8% per year to develop a clot.

4. Smoking, estrogen therapy, pregnancy and recent surgery are situations known to increase the chance of blood clots in any person, however the effects can be more pronounced in people with FVL

5. If a person with FVL develops a second clot, he or she is a candidate for lifelong anticoagulation (blood thinning) therapy.


1. Learning About Factor V Leiden Thrombophilia. Retrieved on August 28, 2016 from

Marco A. Ramos MD

Monday, August 15, 2016

Tips for Great Clinical Documentation Part 2.

In the previous post of the series, I outlined the importance of being specific when documenting in a medical chart. In this post I am going to stress the importance of documenting uncertainty and how to use it to reflect decision making by a physician or advanced practice provider.

Terms like probable, possible, likely or “not ruled out” are acceptable

Many decisions that providers make when practicing medicine are not the direct result of knowing a diagnosis, but a logical decision based on a probability. A typical example of this is the treatment for “healthcare associated pneumonia” (HAP). First of all, just documenting HAP is not  enough for a coder. Here, the provider has to be specific, stating what is he or she treating. The problem arises when the specific bacteria that is causing the HAP is not known. A way to deal with this is to use the following rationale: It is known that is is highly likely that HAP could be caused by pseudomonas because of the exposures these kind of patients have had. For this reason, the provider can cover for that pathogen based on a high probability, not on a certainty.

The documentation may read as follows: “Healthcare Associated Pneumonia. Probable Pseudomonas. Covered with cefepime.” By documenting like this, the provider was specific, showed the seriousness of the condition and justified a use of resource based on a probability.

Marco A. Ramos MD
Second Medical Opinions PLC
Physician Advisor in Clinical Documentation