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LCD Reference Article Billing and Coding Article

Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities

A58250

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Draft Article
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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General Information

Source Article ID
N/A
Article ID
A58250
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities
Article Type
Billing and Coding
Original Effective Date
12/27/2020
Revision Effective Date
03/11/2021
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (CCI)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

National Correct Coding Initiative:

  • NCCI Policy Manual for Medicare Services
    • Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services.
    • Chapter 5 Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes 30000-39999), Section D Cardiovascular System.
    • Chapter 9 Radiology Services (CPT codes 70000-79999), Section D Interventional/Invasive Diagnostic Imaging, Section G Medically Unlikely Edits (MUEs), and Section H General Policy Statements.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38720 Treatment of Chronic Venous Insufficiency of the Lower Extremities. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

The sclerosant used in sclerotherapy procedures is included in the procedure code and is not separately reported.

Liquid sclerotherapy is reported using CPT codes 36468, 36470, and 36471.

Non-compounded foam (NCF) sclerotherapy, for treatment of incompetent extremity truncal veins, is reported using CPT codes 36465 and 36466.

Non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent extremity veins, is reported using CPT codes 36470 and 36471.

Physician-compounded foam (PCF) sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent extremity veins, is reported using CPT codes 36470 and 36471.

The Curent Procedural Terminology (CPT) Professional edition code book states that when performed in the office setting, all required supplies and equipment are included in 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, and 36483 and may not be separately reported. In addition, application of compression dressing(s) (e.g., compression bandages/stockings) is included and may not be separately reported.

According to the CPT Professional edition code book, CPT codes 37241-37244 are used to describe vascular embolization and occlusion procedures excluding the ablation/sclerotherapy procedures for venous insufficiency/telangiectasia of the extremities/skin, which are reported using 36468, 36470, and 36471. “For sclerosis of veins or endovenous ablation of incompetent extremity veins, see 36468-36479.” CPT code 37241 is not appropriate for reporting of vein ablation for the treatment of chronic venous insufficiency of the lower extremities and is incorrect coding.

Per the NCCI Policy Manual for Medicare Services, Chapter 5, Section D., Subsection 43, “Ligation procedures of the lower extremity (e.g., CPT codes 37700-37785) include application of a compression dressing, if performed. CPT code 29581 (application of multi-layer compression system) shall not be reported separately.”

Utilization Parameters

CPT code 36468 should be reported for the treatment of symptomatic spider veins/telangiectasia in the lower extremities by injection of sclerosing agents. According to the CPT Professional edition code book, it may only be reported once per extremity per session, regardless of the number of injections performed.

Per the CPT Professional edition code book, “codes 36474, 36476, 36479, and 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.”

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. Documentation must include a plan of care, for a 90 day episode of care, that supports the evaluation of the patient including a history, physical examination, CEAP clinical classification, VCSS and a formal venous duplex scan.
      • The timing of an intervention(s) must be outlined versus the timing of routine post-op (post procedure) follow-up (for example, procedure(s) on day 1 and reevaluation in 3 months versus procedure(s) on day 1 and 7 and reevaluation in 3 months). Therefore, any planned thermal ablation, and/or sclerotherapy, and/or cyanoacrylate/chemical adhesive ablation, and/or mechanochemical ablation, and/or surgical treatments must be addressed in the plan of care – and must be supported in a complete operative procedure note.
      • Serial ablation procedures on the same leg within a 90 day episode of care must clearly be supported in the documentation based on patient specific clinical information that the ablation procedures cannot be performed on a single day.
      • Incompetent perforator vein intervention must be clearly supported in the documentation based on patient specific clinical information as outlined in the LCD covered indications.
      • The initial plan of care is expected to address all sites of clinically significant axial or non-axial reflux along with a description of the specific procedure(s) to be used in a 90 day episode of care consistent with the CEAP and VCSS classification and supporting clinical and diagnostic data.
      • The plan of care must include the date(s) of the examination and diagnostic evaluation.
      • For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of conservative therapy (2-4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing.
  5. Duplex scan documentation must confirm the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous or perforator veins is 500 milliseconds or greater, and absence of deep venous obstruction.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1

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 Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(49 Codes)
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It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, and 37785.

 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
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
I87.2 Venous insufficiency (chronic) (peripheral)
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
I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity
I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity
I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity
Q27.8* Other specified congenital malformations of peripheral vascular system
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*The venous malformations ICD-10-CM diagnosis code (Q27.8, other specified congenital malformations of peripheral vascular system) only applies to the foam sclerotherapy CPT codes 36465, 36466, 36470, and 36471.

Group 2

(3 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 36468.

 Group 2 Codes
Code Description
D69.8 Other specified hemorrhagic conditions
I78.0 Hereditary hemorrhagic telangiectasia
R58 Hemorrhage, not elsewhere classified
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)
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All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

 Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS 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.

Code Description

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Other Coding Information

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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
03/11/2021 R1

Article revised and published 03/11/2021 effective for dates of service on and after 03/11/2021. The billing guidance section has been revised to clarify reporting of Non-compounded sclerotherapy and Physician-compounded sclerotherapy services.

Also, minor template changes made throughout the article.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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