Procedure Codes and Description

Group 1 Paragraph: 36299* is used for sclerotherapy with mechanical agitation (e.g. Clarivein® device).

37799* should be used to report “Trivex Procedure”

36299 UNLISTED PROCEDURE, VASCULAR INJECTION

36470 INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN

36471 INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG

36473 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED

36474 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

36476 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED

36479 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS

37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN

37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW

37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA

37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), INCLUDING SKIN GRAFT, WHEN PERFORMED, OPEN,1 LEG

37761 LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG

37765 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS

37766 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS

37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)

37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1 LEG

37799 UNLISTED PROCEDURE, VASCULAR SURGERY

93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY

93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY

Billing and Coding Update

1. Initial authorization for sclerotherapy will be for 3 sclerotherapy treatments (CPT 36471) per leg as medically necessary. If further sclerotherapy treatments are requested, new recent photos (within I month of the requested procedure) with updated clinical information (post-treatment) will be necessary for review.

2. Coverage of laser and RFA is indicated for small/great saphenous veins and anterior/posterior accessory saphenous veins to improve symptoms attributable to saphenofemoral or saphenopopliteal reflux when medical necessity criteria are met. (Maximum allowable vein diameters: ELAS — 20mm; RFA — 18mm)

3. There should be no thrombosis that would interfere with intraluminal procedures.

4. There should be no aneurysm in the target segment.

5. Ultrasound guidance is not covered separately and is included in CPT codes 36478 and 36479.

6. One pre-operative Doppler ultrasound study or duplex scan will be covered.

7. One post-procedure Doppler ultrasound study or duplex scan will be covered.

The use of ultrasound guidance procedures during varicose vein surgery should not be billed separately; these CPT codes are 76937, 76942, 76998, 76999, 93965, 93970, 93971 and S2202. (Note: Intraoperative ultrasound is covered for Medicare members only)

8. Selective catheter placement (CPT 36011) is included in procedures used to treat the varicose veins.

9. A procedure performed on the same vessel, above and below the knee, is considered the same procedure if done within a 3-month period.

10. For ablations only a single date of service will be authorized per leg (i.e., all of the symptomatic axial veins in a
single leg will be treated on one date of service). Only one primary ablation CPT code and one secondary ablation CPT code will be used to treat all of the axial veins in one leg.

11. Sclerotherapy should not occur sooner than three months after an ablation procedure (VNUS, ELAS or EVLT), ligation and stripping, or phlebectomy since elimination of the larger vessels may cause the smaller venous to significantly decrease in size.

12. Currently, a CPT code does not exist to describe the microfoam endovenous ablation procedure with ultrasound, therefore 37799 should be used with a crosswalk to 36475-36479, and 37765 with percutaneous endovenous ablation in box 19 or the electronic equivalent.

13. Currently, a specific J-code does not exist for Varithena; therefore J3490 should be used with appropriate NDC number.

* There is no specific CPT code for transilluminated powered phlebectomy. Providers might elect to use CPT codes describing stab phlebectomy (37765 or 37766) or unlisted vascular surgery procedure (37799).

* Mechanochemical ablation should be reported with procedure code 37799.

* There is no specific CPT for microfoam sclerotherapy. Providers might elect to use CPT codes describing sclerotherapy (36468-36471) or the unlisted vascular surgery procedure code 37799. Use of codes 36475-36476 would be inappropriate as the procedure is not ablation therapy.

* Note: The bulk of the literature discussing the role of ultrasound guidance refers to sclerotherapy of the saphenous vein, as opposed to the varicose tributaries. If ultrasound guidance (CPT code 76942) is used to guide sclerotherapy of the varicose tributaries, it would be considered content of service to the injection procedure.

Coverage Indications, Limitations, and/or Medical Necessity

Varicose veins are caused by venous insufficiency as a result of valve reflux (incompetence). The venous insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Spider veins (telangiectases) are dilated capillary veins that are most often treated for cosmetic purposes. Treatment of telangiectases (36468) is not covered by Medicare.

Historically, varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and avoidance of prolonged immobility. When conservative measures are unsuccessful, and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping. Sclerotherapy involves the injection of a sclerosing solution into the varicose vein(s).

Compressive sclerotherapy is the injection of the sclerosant into an empty vein (elevated limb) followed by application of a compressive bandage or dressing. This is the most commonly performed sclerotherapy procedure for varicose veins of the lower extremity. Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. It is not considered an appropriate option for large, extensive or truncal varicosities. Foam sclerotherapy is FDA indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein (GSV) system above and below the knee. It is usually given with ultrasound guidance. Non-Compressive sclerotherapy is not covered by Medicare.

More recently, endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to sclerotherapy and surgical intervention. These procedures are designed to damage the intimal wall of the vein resulting in fibrosis and subsequent ablation of the lumen of a segment of the vessel. Both procedures utilize specially designed catheters inserted through a small incision in the distal thigh and advanced, often under ultrasound guidance, nearly to the saphenofemoral junction. The catheter is then slowly withdrawn while controlled radiofrequency or laser energy is applied. This is followed by external compression of the treated segment.

Doppler ultrasound or duplex studies are often used to map the anatomy of the venous system prior to the procedure. There is adequate evidence that pre-procedural ultrasound is helpful, and Medicare will cover one ultrasound or duplex scan prior to the procedure to determine the extent and configuration of the varicosities.

Evidence and clinical experience supports the use of ultrasound guidance during the procedure (ERFA and laser ablation only) and shows that the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. The CPT codes for radiofrequency and laser include the intraoperative ultrasound service in the valuation and ultrasound may not be billed separately with these procedures.

In contrast to ERFA and laser procedures, intra-operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of sclerotherapy for varicose veins, therefore, intra-operative ultrasound guidance will not be separately covered for sclerotherapy.

A. Indications for surgical treatment (CPT codes: 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785) and sclerotherapy (CPT codes: 36470, 36471):

1. A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND

2. The patient is symptomatic and has one, or more, of the following:
a. Pain or burning in the extremity severe enough to impair mobility
b. Recurrent episodes of superficial phlebitis
c. Non-healing skin ulceration
d. Bleeding from a varicosity
e. Stasis dermatitis
f. Refractory dependent edema

B. Indications for ERFA or laser ablation (CPT codes 36475, 36476, 36478, 36479):

In addition to the above (see A), the patient’s anatomy and clinical condition are amenable to the proposed treatment including ALL of the following:

1. Absence of aneurysm in the target segment.
2. Maximum vein diameter of 12 mm for ERFA or 20 mm for laser ablation
3. Absence of thrombosis or vein tortuosity, which would impair catheter advancement. –4. The absence of significant peripheral arterial diseases.

C. Limitations for ERFA and laser ablation:
1. ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy.
2. Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation, and sclerotherapy.
3. The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3-month trial of conservative measures, by any technique will be considered cosmetic and therefore not covered.
4. The treatment of spider veins or superficial telangiectasis by any technique is considered cosmetic, and therefore not covered.
5. Coverage is only for devices specifically FDA-approved for these procedures.
6. One pre-operative Doppler ultrasound study or duplex scan will be covered.

Noridian notes that stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian notes that if sclerotherapy is used with endovenous radiofrequency ablation, it may be covered if the criteria for reasonable and necessary as described in this LCD are met.

Noridian will not consider the treatment of asymptomatic veins with endoluminal ablation or sclerotherapy medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic – Rural Health
077x Clinic – Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
999x Not Applicable


Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to Part A.
0330 Radiology – Therapeutic and/or Chemotherapy Administration – General Classification
0360 Operating Room Services – General Classification
0490 Ambulatory Surgical Care – General Classification
0510 Clinic – General Classification
0520 Freestanding Clinic – General Classification

Coverage Guidance

Historically, varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy and avoidance of prolonged immobility. When conservative measures are unsuccessful, and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping. Sclerotherapy involves the injection of a sclerosing solution into the varicose vein(s).

More recently, endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to sclerotherapy and surgical intervention. These procedures are designed to damage the intimal wall of the vein resulting in fibrosis and subsequent ablation of the lumen of a segment of the vessel. Both procedures utilize specially designed catheters inserted through a small incision in the distal thigh and advanced, often under ultrasound guidance, nearly to the saphenofemoral junction. The catheter is then slowly withdrawn while controlled radiofrequency or laser energy is applied. This is followed by external compression of the treated segment.

Doppler ultrasound or duplex studies are often used to map the anatomy of the venous system prior to the procedure. There is adequate evidence that pre-procedural ultrasound is helpful, and Medicare will cover one ultrasound or duplex scan prior to the procedure to determine the extent and configuration of the varicosities when it is medically necessary.

Evidence and clinical experience supports the use of ultrasound guidance during the procedure and shows that the outcomes may be improved and complication rates may be minimized when ultrasound guidance is used. The CPT codes for radiofrequency and laser include the intra-operative ultrasound service in the valuation and ultrasound may not be billed separately with these procedures.

A duplex ultrasound examination is considered medically necessary and will be allowed when performed within 1 week (preferably within 72 hours) of EFRA to check for any evidence of thrombus extension from the saphenofemoral junction into the deep system.

A. Indications for surgical treatment and sclerotherapy:
A 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND

The patient is symptomatic and has one, or more, of the following:
Pain, aching, cramping, burning, itching and/or swelling during activity or after prolonged standing severe enough to impair mobility

Recurrent episodes of superficial phlebitis

Non-healing skin ulceration

Bleeding from a varicosity

Stasis dermatitis

Refractory dependent edema

The treatment of spider veins/telangiectasis will be considered medically necessary only if there is associated hemorrhage.

B. Indications for ERFA or laser ablation:

In addition to the above (see A), the patient’s anatomy and clinical condition are amenable to the proposed treatment including ALL of the following:
Absence of aneurysm in the target segment.

Maximum vein diameter of 20 mm for ERFA or 30 mm for laser ablation.

Absence of thrombosis or vein tortuosity, which would impair catheter advancement.

The absence of significant peripheral arterial diseases.

C. Limitations for ERFA and laser ablation:

ERFA and laser ablation are covered only for the treatment of symptomatic varicosities of the lesser or greater saphenous veins and their tributaries which have failed 3 months of conservative therapy.

Intra-operative ultrasound guidance is not separately payable with ERFA, laser ablation.

The treatment of asymptomatic varicose veins, or symptomatic varicose veins without a 3-month trial of conservative measures, by any technique, will be considered cosmetic and therefore not covered.

The treatment of spider veins or superficial telangiectasis by any technique is also considered cosmetic, and therefore not covered unless there is associated bleeding.

Coverage is only for devices specifically FDA-approved for these procedures.

One pre-operative Doppler ultrasound study or duplex scan will be covered.

Post –procedure Doppler ultrasound studies will be allowed if medically necessary.

The stab phlebectomy of the same vein performed on the same day as endovenous radiofrequency or laser ablation may be covered if the criteria for reasonable and necessary as described in this LCD are met.

If sclerotherapy is used with endovenous ablation, it may be covered if the criteria for reasonable and necessary as described in this LCD are met.

The treatment of asymptomatic veins with endoluminal ablation or sclerotherapy is not considered medically reasonable and necessary. If it is determined on review that the varicose veins were asymptomatic, the claim will be denied as a noncovered (cosmetic) procedure.

ICD-10 Codes that Support Medical Necessity




ICD-10 CODE DESCRIPTION

I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.11 Varicose veins of right lower extremity with inflammation
I83.12 Varicose veins of left lower extremity with inflammation
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.811 Varicose veins of right lower extremities with pain
I83.812 Varicose veins of left lower extremities with pain
I83.813 Varicose veins of bilateral lower extremities with pain
I83.891 Varicose veins of right lower extremities with other complications
I83.892 Varicose veins of left lower extremities with other complications
I83.893 Varicose veins of bilateral lower extremities with other complications
I87.001 Postthrombotic syndrome without complications of right lower extremity
I87.002 Postthrombotic syndrome without complications of left lower extremity
I87.003 Postthrombotic syndrome without complications of bilateral lower extremity
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.021 Postthrombotic syndrome with inflammation of right lower extremity
I87.022 Postthrombotic syndrome with inflammation of left lower extremity
I87.023 Postthrombotic syndrome with inflammation of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.091 Postthrombotic syndrome with other complications of right lower extremity
I87.092 Postthrombotic syndrome with other complications of left lower extremity
I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity
I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity
I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity