# Endovascular treatment of venous malformations



## smwaters (Mar 18, 2009)

I'm at a Children's Hospital and we often treat venous malformations all over the body.  Sometimes they are categorized as bleb nevus sydrome as in the case below.  I don't think 36468-36471 are appropriate since those are for spider veins.  It has been recommended by an ex IR physician who now works for a coding company to use 61626 or 37205.

Excerpt from report:  Sonographic guidance was used to cannulate multiple venous malformations using 20-gauge catheters and 21-gauge echo-tipped needles.  The larger sites were evaluated with contrast venography, digital subtraction technique, which were recorded.  Smaller lesions were injected directly using sonographic guidance to confirm intralesional injection.  After treating these sites that were prepped, the left forearm and hand was sterilely prepared and draped in treated. The patient was then rolled onto his left side and the mid posterior chest wall was sterilely prepared.  One superficial lesion near the spinous process of T2 was injected.  

Right elbow.  This was evaluated but no venous malformation was identified and no injection was made.  
Right middle finger.  0.75 units of bleomycin was injected in two sites under the nailbed.  
Right ring finger.  Syrup 0.5-ML bleomycin, one unit/ML, was injected into the finger tip in nail bed.  
Right anterior abdominal wall.  Three amount of 3% STS foam followed by 3amount [3 units] bleomycin were injected.  The site was compressed.  
Left lower anterior abdominal wall.  A small sessile lesion was injected with 2.5-ML of half-strength bleomycin  
Left foot.  Third toe, one unit of bleomycin, second toe, syrup 0.5-ML bleomycin, superficial lesion on the sole of the foot, one ML bleomycin.  
Right foot.  Venous malformation dorsal surface, 0.5-ML bleomycin.  Right great toe deep lesion, 0.5-ML STS followed by bleomycin 0.5 units with compression.  
Left dorsal forearm one ML of bleomycin  
Left wrist, flexor surface one ML STS, second lesion on ML STS  
Left ring finger distal one ML STS  
Left middle finger, distal, one ML STS  
Right index finger, distal, one ML STS  
Proximal mid posterior thorax,  0.5-ML STS  
Right lateral proximal thigh,  0.5-ML STS  

Thoughts, ideas?  Anything advice is greatly appreciated.  I'm hoping someone out there deals with these and at the very least can tell me how they handle them.


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## Shirleybala (Mar 26, 2009)

I think that as per documentation we can code 36468

36468	Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

The physician inserts a tiny needle through the skin and directly into the tiny, distended veins in the arms, legs, or trunk. A solution (hypertonic saline and other solutions) is injected into these veins. The solution causes the walls of the veins to become inflamed, collapse, and stick together so the veins close.
*Venous Malformation Means:*
1)Venous malformations comprise either superficial or deep veins that are abnormally formed and dilated. The walls of these vessels are thin because they lack smooth muscle. They are the most common type of vascular malformation. Although they usually are present at birth, they may not be seen until years later. The natural history of a venous malformation is slow, steady enlargement.
*Treatment:*
2)Sclerotherapy. This approach entails injecting an irritating solution into the lesion in order to shrink the abnormal veins. For larger lesions, it is sometimes used along with surgical excision. Multiple treatments are often required over time.


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## desertcoder (Mar 31, 2009)

*Endovascular tx olf venous malformation*

Is there any reason that 37204 could NOT be used? This coed describes using a catheter to occlude a vascular malformation. I know this is primarily to occlude vessels  in a tumor, but it is NOT the only function of this code. The accompanying 75894 for the radiology portion and is not specific to ultrasound, but I would think that it could still be used. Any thoughts?


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## dpeoples (Apr 3, 2009)

desertcoder said:


> Is there any reason that 37204 could NOT be used? This coed describes using a catheter to occlude a vascular malformation. I know this is primarily to occlude vessels  in a tumor, but it is NOT the only function of this code. The accompanying 75894 for the radiology portion and is not specific to ultrasound, but I would think that it could still be used. Any thoughts?



I would also consider the above scenario sclerotic therapy. The lesions are being directly injected (through needle or catheter) with a sclerosiing agent. 
In embolization/occlusion (37204, 61624,61626) the blood flow is the target. Some type of embolitic material/agent is being placed in the artery/vein to block the flow of blood to the tumor or malformation. 

btw I could not find "bleb nevous syndrome" in any of my material, nor could I find "spider veins" in my ICD9. I did find "spider nevous" and assumed that was the diagnosis code that would fit the procedure.


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