General Surgery Coding Alert

Question: Payers routinely reject our claims for varicose vein injections. What are we doing wrong? Colorado Subscriber   Answer: Physicians can treat distended, lengthened and/or tortuous (that is, varicose) veins by injecting an irritant solution to encourage obliteration of the veins by thrombosis and subsequent scarring (a technique known as sclerotherapy). Sclerotherapy is useful primarily for managing smaller varicose veins and for recurrent or persistent varicosities after operative treatment (that is, 37720-37730). The appropriate CPT codes to describe such injections are 36470* (Injection of sclerosing solution; single vein) and 36471* ( multiple veins, same leg). Some insurers consider such injections to be primarily cosmetic and, therefore, not reimbursable due to lack of medical necessity. Other insurers will reimburse for these procedures for a limited number of diagnoses under specific (noncosmetic) circumstances. For example, Noridian Mutual Insurance Company, a Part B provider for Alaska, Arizona, Colorado, Hawaii, Iowa and six other Western states, specifies (draft policy 2003.12) that the only covered diagnoses for 36470/36471 are 454.0-454.9 (Lower extremity varicose veins) and that the patient record must document all of the symptoms and physical findings, location and number of varicosities, level of incompetence of vein, the veins involved, and the number of perforators treated. In addition, the medical record must document that the physician has tried less invasive therapies and they have failed. Note: Noridian and other payers specifically prohibit reimbursement for 36468 (Single or multiple injections of sclerosing solutions, spider veins [telangiectasia]; limb or trunk) or for diagnoses other than 454.0-454.9. The best route is to obtain preauthorization (in writing) prior to the injections. If the insurer will not preauthorize the treatment, or the patient requests sclerotherapy for spider veins (448.1) or any other uncovered diagnosis, you will have to present the patient with an advance beneficiary notice (ABN) and collect payment directly from him or her.