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.
