Dermatology Coding Alert

Tip: Treatments can be the same for spider veins and varicose veins, but be familiar with the different options.

With treatments for spider veins and varicose veins becoming common in dermatology practices, you need to be aware of the rules for coding and billing these procedures – and on the lookout for these myths that could be holding you back from your deserved reimbursement.

Myth: Spider veins and varicose veins are interchangeable terms.

Reality: They are very different – not only in presentation, but also in reimbursement rules, say experts.

The problematic veins your dermatologist is most likely to be faced with fall into two categories: spider veins and varicose veins.

Spider veins: Also known as telangiectases or roadmap veins, these are “very tiny superficial blood vessels that increase in size over time and commonly occur on the legs,” according to the American Academy of Dermatology.

ICD-10 has one diagnosis code that covers spider veins: I78.1 (Nevus, non-neoplastic).

Varicose veins: These are larger, dilated blood vessels that can be raised above the skin’s surface and have a rope-like appearance, the AAD says.

ICD-10 has several dozen codes that describe diagnoses of varicose veins, many of which are in the I83.-- (Varicose veins of lower extremities) category. The codes are further specified by which lower extremity is affected (left or right), and whether the ulcers or other conditions are also present. For more information, see “I83.--- Family Covers Varicose Veins of Lower Extremities” in this issue.

However: Don’t count on reimbursement from Medicare for spider vein treatments. As Part B carrier National Government Services puts it in its local coverage determination (LCD), “Spider veins … are most often treated for cosmetic purposes. Treatment of telangiectases is not covered by Medicare.”

Myth: Treatment for varicose and spider veins are always different.

Reality: Even though the conditions are different (and have different rules for payability), dermatologists treat spider and varicose veins in some cases with the same procedures. A common treatment of both is an injection of medicine into the affected blood vessels to shrink them. These injections of sclerosing solutions are described with CPT^® codes 36468-36471:

• 36468 — Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
• 36470 — Injection of sclerosing solution; single vein
• 36471 — … multiple veins, same leg.

Myth: Sclerosing injections are the only allowable option for treating varicose veins.

Reality: Dermatologists often turn to other methods besides sclerosing injections to treat varicose veins. Ligation and stripping is a proven treatment for varicose veins, reported by dermatologists with CPT^® codes:

• 37718 — Ligation, division, and stripping, short saphenous vein
• 37722 — … long (greater) saphenous veins from saphenofemoral junction to knee or below
• 37780 — Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure)
• 37785 — Ligation, division, and /or excision of varicose veins (clusters), one leg.

Another therapy for treating varicose veins is radiofrequency, says the AAD. During this procedure, radiofrequency energy converted to heat is used to collapse the vein, which is then reabsorbed by the body, the Academy explains. Radiofrequency is described by CPT^® codes:

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

Laser therapy is one of the latest treatments for varicose veins, in which tiny laser fibers are delivered to the vein through a needle puncture that is threaded up to the main vein trunk responsible for these veins, says the AAD. This is described by CPT^® codes:

• 36478 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
• 36479 — … second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).

Myth: Interventional treatment of varicose veins is automatically considered medically necessary.

Reality: Although Medicare has no national coverage determination (NCD) for varicose vein treatments, several local Part B carriers, such as National Government Services, have LCDs. NGS’s policy states that Medicare will consider interventional treatment of varicose veins medically necessary if the patient remains symptomatic after a six-week trial of conservative therapy. The components of the conservative therapy include, but are not limited to:

• Weight reduction,
• A daily exercise plan,
• Periodic leg elevation
• The use of graduated compression stockings.

“The conservative therapy must be documented in the medical record,” says NGS.

The patient is considered symptomatic if any of the following signs and symptoms of significantly diseased vessels of the lower extremities are documented in the medical record, the Part B carrier says:

• Stasis ulcer of the lower leg
• Significant pain and significant edema that interferes with activities of daily living
• Bleeding associated with the diseased vessels of the lower extremities
• Recurrent episodes of superficial phlebitis
• Stasis dermatitis
• Refractory dependent edema.

The patient's medical record must contain documentation that fully supports the medical necessity for services, cautions NGS. “This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.”

Specifically, the LCD requires that the patient's medical record must document:

• History and physical findings supporting a diagnosis of symptomatic varicose veins
• Failure of an adequate trial of conservative treatment
• Exclusion of other causes of edema, ulceration and pain in the limbs
• Performance of appropriate tests to confirm the presence and location of incompetent perforating veins
• Location and number of varicosities, level of incompetence of the vein and the veins involved
• Necessity of utilizing ultrasound guidance, if used.

“The medical record must also include pre-treatment photographs of the varicose veins for which claims for sclerotherapy are submitted to Medicare,” says NGS. “These photographs must be made available to the carrier upon request for review.”