General Surgery Coding Alert

CPT® 2017:

Focus Your MOCA Vein Treatments with 36473 and 36474

Published on Fri Mar 10, 2017

Learn limitations of two new codes.

If your surgeons are using the latest technology for treating incompetent extremity veins, you might be happy to find a new way to report the service without turning to an “unlisted” code.

From now on, you can use one of the following codes when your patients receive mechanochemical ablation (MOCA) treatment for lower-extremity vein(s):

36473 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
+36474 — … subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).

Old way: If your surgeon has used this method in past years, your only choice was an unlisted code to report the service, 37799 (Unlisted procedure, vascular surgery).

Distinguish MOCA from Other Methods

Surgeons have various methods for endovascular ablation of incompetent extremity veins, including injection of sclerosant or chemical adhesive, or radiofrequency or laser ablation.

Now there’s a relatively new method available that involves both mechanical and chemical processes to accomplish closing off the insufficient vein (venous occlusion).

The MOCA procedure includes using both a device that mechanically damages the venous intima, and administering a sclerosant to the target vein, stated Katharine L. Krol, MD, FSIR, FACR, CPT^®editorial panel member, at the AMA’s CPT^®and RBRVS 2017 Annual Symposium.

Differentiate 36473, +36474: For code 36473, the surgeon localizes and performs the procedure for the initial target vein, such as the greater saphenous vein. If the surgeon then localizes and performs the mechanochemical ablation in a second or more subsequent target veins through different access site(s), add +36474 to your billing.

Vascular Insights, LLC obtained these CPT^®codes for their ClariVein^®mechanochemical system, according to A.J. Riviezzo, of American Physician Financial Solutions in Colorado Springs, in his Vein Notes Blog.

Know What Codes Include

The new MOCA procedures encompass many steps, but you need to be careful not to separately bill for any part of the service that the codes inherently include.

The procedure includes the following steps:

Localize, map, and mark target vein using ultrasound (US) guidance.
Employ local anesthesia, typically with no need for tumescent anesthesia (subcutaneous infiltration of saline, epinephrine and lidocaine fluid in the peri-saphenous region)
Under US guidance, access vein, introduce guidewire, then advance dilator over wire and exchange for sheath
Still using US guidance, advance treatment catheter the length of the vein and perform mechanochemical ablation through the catheter
Document final status through US and physical exam of extremity before removing catheter and sheath and placing compression stocking on the extremity.

Codes 36473 and +36474 include every one of those documented steps. That means the codes include all imaging guidance and monitoring, which typically involves US. The codes also cover all supplies and equipment in the office setting.

Understand Unit of Service

Both 36473 and +36474 describe all mechanochemical ablation services on a given date of service for a single extremity.

Code 36473 stands alone for a single vein treatment in one leg. Use this code for the first vein treated, such as the greater saphenous vein.

Never use +36474 as a stand-alone code. Report this code only in addition to 36473 for subsequently treated vein(s) on the same date of service.

Caution: Unlike many add-on CPT^®codes, you should not report +36474 for “each additional.” “Use this code just one time no matter how many additional veins the surgeon treats in the same extremity on the same date,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of clinics with Encounter Telehealth in Omaha, Nebr.

Avoid These Bundles

When you report your surgeon’s procedure for venous occlusion by endovascular ablation to treat incompetent extremity veins, you need to distinguish various methods and choose the most specific code. That means you need to be aware of your other choices, such as the following code families:

36475 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated and + 36476 (…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, and +36479 (… subsequent vein[s] treated in a single extremity, each through separate access sites [List separately in addition to code for primary procedure]).

Surgeons may also use procedures that don’t have a specific CPT^®code, such as injection of liquid or foam sclerosant directly into the vein without mechanically disrupting the vein. Even if the final step is compression application, that does not count as a “mechanical” component to qualify for the new codes. Or, the surgeon may treat the veins by injecting a chemical adhesive. You should continue to report these procedures using 37799.

Because codes 36475-+36479 describe alternate methods (radiofrequency or laser ablation) to achieve the same treatment effect as 36473-+36474, you should choose just one code family that best describes your surgeon’s work, and never report the code families together for the same extremity on the same day.

Avoid: Make sure you don’t unbundle and bill separately for steps that are inherent in the 36473-+36474 procedures. That includes all imaging guidance, venous access, and supplies and equipment. Because of this bundling rule, you’ll find CPT^®text notes and Correct Coding Initiative (CCI) edit pairs restricting you from billing for any of the following services with 36473-+36474 for the same surgical field: