Patient had an endovenous radiofrequency ablation of the anterior and posterior branch of the right greater saphenous vein. It is the same vein just two different branches off the vein.
After informed consent was obtained, the right leg was prepped and draped in usual fashion. Using Seldinger technique, access was obtained in the anterior branch of the greater saphenous vein in the mid to distal thigh. A 7-French sheath was placed over the wire and the radiofrequency catheter was inserted through the sheath and confirmed on ultrasound to be approximately 3 cm distal to saphenofemoral junction. After this, the access obtained to the posterior branch of the right greater saphenous vein and a wire was left into place. Next using 0.1% lidocaine with lactated Ringers, the area about the anterior and posterior branch of the right greater saphenous vein were anesthetized. Next using 15 cycles of radiofrequency energy, 20 cm anterior branch of the right greater saphenous vein was ablated. Pressure was held at this location and the 7-French sheath was re-loaded and reinserted back over the wire into the posterior branch. The radiofrequency catheter was then inserted through the sheath and confirmed on ultrasound to be greater than 3 cm distal to saphenofemoral junction. Next using 6 cycles of radiofrequency energy with a 3 cm catheter, 9 cm posterior branch of the right greater saphenous vein was ablated. The patient tolerated the procedure well. Restrictions and expectations as well as pain and discomfort, discoloration, and hardening were discussed as possibilities. The leg was wrapped and the patient ambulated prior to discharge.
Should I code 36475 RT and 36476 RT?
CPT Code 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
CPT Code 36476 Subsequent vein(s) treated in a single extremity, each through separate access sites(list separately in addition to code for primary procedure)
After informed consent was obtained, the right leg was prepped and draped in usual fashion. Using Seldinger technique, access was obtained in the anterior branch of the greater saphenous vein in the mid to distal thigh. A 7-French sheath was placed over the wire and the radiofrequency catheter was inserted through the sheath and confirmed on ultrasound to be approximately 3 cm distal to saphenofemoral junction. After this, the access obtained to the posterior branch of the right greater saphenous vein and a wire was left into place. Next using 0.1% lidocaine with lactated Ringers, the area about the anterior and posterior branch of the right greater saphenous vein were anesthetized. Next using 15 cycles of radiofrequency energy, 20 cm anterior branch of the right greater saphenous vein was ablated. Pressure was held at this location and the 7-French sheath was re-loaded and reinserted back over the wire into the posterior branch. The radiofrequency catheter was then inserted through the sheath and confirmed on ultrasound to be greater than 3 cm distal to saphenofemoral junction. Next using 6 cycles of radiofrequency energy with a 3 cm catheter, 9 cm posterior branch of the right greater saphenous vein was ablated. The patient tolerated the procedure well. Restrictions and expectations as well as pain and discomfort, discoloration, and hardening were discussed as possibilities. The leg was wrapped and the patient ambulated prior to discharge.
Should I code 36475 RT and 36476 RT?
CPT Code 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
CPT Code 36476 Subsequent vein(s) treated in a single extremity, each through separate access sites(list separately in addition to code for primary procedure)