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

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.