LCD Reference Article Billing and Coding Article

Billing and Coding: Treatment of Varicose Veins of the Lower Extremity

A52870

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A52870
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Treatment of Varicose Veins of the Lower Extremity
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
11/21/2019
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Treatment of Varicose Veins of the Lower Extremity. 

National Coverage Provisions:

Cosmetic surgery is statutorily excluded from coverage by Medicare. The following interventional treatments are considered to be cosmetic and will be denied as such:

  • Interventional treatment of asymptomatic varicosities.
  • Treatment of telangiectases (CPT code 36468).
  • Sclerotherapy for cosmetic purposes.


Coding Guidelines:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.

Specific coding guidelines:

It is inappropriate to report CPT code 37241 for the treatment of superficial varicose veins of the lower extremity.

CPT code 36470 should be used when only one vein is injected on a given date of service.

CPT codes 36466, 36471 may be reported once per extremity, regardless of the number of veins treated.

CPT codes 36474, 36476, 36479, 36483 for subsequent vein(s) treated in the same extremity may only be reported once per extremity, regardless of the number of additional vein(s) treated.

When performed in the office setting, all required supplies and equipment are included in CPT codes 36465, 36466, 36470, 36471 and may not be reported separately.

When performed in the office setting, all required supplies and equipment are included in CPT codes 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483 and may not be reported separately.

For providers other than Ambulatory Surgical Centers (ASC), the appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned as unprocessable.

For an ASC, the appropriate site modifier (RT and/or LT) must be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (50 modifier should not be used). Services reported without a modifier will be returned as unprocessable.

CPT code 37799 used to describe the Trivex procedure should include the words “Trivex procedure” in the remarks field of the claim form. (For claims filed with the Part B MAC, use Item 19 on the CMS 1500; for claims filed with the Part A MAC, use FL 80 on the CMS 1450.)

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The patient's medical record must document the following:

  • history and physical findings supporting a diagnosis of symptomatic varicose veins;
  • failure of an adequate trial of conservative treatment as described in the "Indications" section of this LCD;
  • exclusion of other causes of edema, ulceration and pain in the limbs;
  • performance of appropriate tests to confirm the presence and location of incompetent perforating veins;
  • location and number of varicosities, level of incompetence of the vein and the veins involved; and
  • necessity of utilizing ultrasound guidance, if used.

The medical record must also include pre-treatment photographs of the varicose veins for which claims for sclerotherapy are submitted to Medicare. These photographs must be made available to the contractor upon request for review.

Utilization Guidelines:

Coverage for podiatrists is limited by scope of practice specific to the state in which the service is provided.

Medicare recognizes that multiple injections are needed to perform sclerotherapy and that responses differ due to the anatomical site being treated. Medicare would not expect to see the following when performing sclerotherapy:

  • More than three sclerotherapy sessions for each leg.
  • Only one sclerotherapy service per treatment session should be reported for either leg, regardless of how many veins are treated per session.

During a single episode of treatment, most patients with C2, C3 and C4a disease require no more than one ablation of one of the GSV, AAGSV, and SSV per leg and nearly all patients require no more than two of these veins to be treated in each lower extremity during an episode of care. Utilization will be monitored statistically and outlier practitioners may be required to submit medical records for audit.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(45 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the attached determination.

CPT Codes 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780 and 37799

Group 1 Codes
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
I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified
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 extremity with pain
I83.812 Varicose veins of left lower extremity with pain
I83.813 Varicose veins of bilateral lower extremities with pain
I83.891 Varicose veins of right lower extremity with other complications
I83.892 Varicose veins of left lower extremity with other complications
I83.893 Varicose veins of bilateral lower extremities with other complications
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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(19 Codes)
Group 1 Paragraph

Use of any ICD-10-CM code not listed in the "ICD-10-CM Codes that Support Medical Necessity" section of this article will be denied.

In addition, the ICD-10-CM codes listed below are specifically included as not supporting medical necessity for emphasis, and to avoid any provider errors.

CPT codes 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780 and 37799 (when used to report "Trivex Procedure"), submitted for any of the following ICD-10-CM codes will be denied as not medically necessary:

Group 1 Codes
Code Description
I78.0 Hereditary hemorrhagic telangiectasia
I78.1 Nevus, non-neoplastic
I78.8 Other diseases of capillaries
I78.9 Disease of capillaries, unspecified
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
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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/21/2019 R9

Updated to indicate the article is an LCD reference article.

11/21/2019 R8

This article was converted to the new Billing and Coding Article format.

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

08/01/2019 R7

The title of the article has been revised to add “Billing and Coding”. The article has been revised to add National Coverage Provisions, ICD-10-CM coding sections, Documentation Requirements and Utilization Guidelines.

01/01/2018 R6

Removed template language.

Removed duplicative and unnecessary coding guidelines.

Added the following instructions from the 2018 CPT Book:

CPT codes 36466, 36471 may be reported once per extremity, regardless of the number of veins treated.

CPT codes 36474, 36476, 36479, 36483 for subsequent vein(s) treated in the same extremity may only be reported once per extremity, regardless of the number of additional vein(s) treated.

When performed in the office setting, all required supplies and equipment are included in CPT codes 36465, 36466, 36470, 36471 and may not be reported separately.

When performed in the office setting, all required supplies and equipment are included in CPT codes 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483 and may not be reported separately.

Added Bill Type Codes 011X, 012X, 013X, 071X, 073X and 077X to be consistent with the LCD.

CPT codes 36465, 36466, 36482 and 36483 were added to the “CPT/HCPCS Codes” section.

01/01/2017 R5 Due to annual HCPCS update, the descriptor was changed for CPT codes 36476 and 36479.
01/01/2016 R4 The following coding guideline was added:

It is inappropriate to report CPT code 37241 for the treatment of superficial varicose veins of the lower extremity.
01/01/2016 R3 References to CPT codes 76942, 93965, 93970 and 93971 were removed from the “Coding Information” and “CPT/HCPCS Codes” sections. Refer to the Non-Invasive Vascular Studies LCD (L33627) for coverage criteria on imaging guidance.

Minor template changes were made to reflect current template language.
11/01/2015 R2 The following coding guidelines were revised to indicate a modifier 50 rather than modifiers LT and RT should be reported when performed as a bilateral procedure:

  1. One vein on the left; two veins on the right: 3647050
  2. One vein on each leg: Use 3647050
10/01/2015 R1 Removed place of service coding guideline.

The following coding guideline was revised to indicate a modifier 50 rather than modifiers LT and RT should be reported when performed as a bilateral procedure:

Two veins on the right; three on the left: Use 3647150.

Added an example of a supply to the following coding guideline:

    e. Supplies and dressings are not separately reimbursed (e.g., liquid or foam sclerosant used in CPT code 36470 or 36471).
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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