Dermatology Coding Alert

Follow our expert insights on treatment options, Dx codes, and documentation. 

Spider vein and varicose vein treatments are increasingly common procedures at dermatology practices — and just as common are the struggles to code and bill them correctly. If a vein treatment is medically necessary, follow the expert advice below to get your deserved reimbursement.

Know the Sclerosing Solution Injection Basics

The problematic veins your dermatologist is most likely to be faced with fall into two categories: spider veins and varicose veins, says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas.

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.

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.

Treatment: A common treatment is an injection of a medicine into the affected blood vessels to shrink them. These injections of sclerosing solutions are described with CPT® codes 36468-36471. 

Medicare rules: CPT® has specific codes for sclerosing injections: 

• 36468 — Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
• 36469 — …face
• 36470 — Injection of sclerosing solution; single vein
• 36471 — … multiple veins, same leg.

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.”

Understand the Varicose Treatments

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).

Prove Medical Necessity

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.

Although not limited to these diagnoses, NGS lists these ICD-9 codes as supporting medical necessity for varicose vein treatments:

• 451.0 — Phlebitis and thrombophlebitis of superficial vessels of lower extremities
• 451.2 — Phlebitis and thrombophlebitis of lower extremities unspecified
• 454.0 — Varicose veins of lower extremities with ulcer
• 454.1 — Varicose veins of lower extremities with inflammation
• 454.2 — Varicose veins of lower extremities with ulcer and inflammation
• 454.8 — Varicose veins of lower extremities with other complications 
• 459.31 — Chronic venous hypertension with ulcer 
• 459.32 — Chronic venous hypertension with inflammation
• 459.33 — Chronic venous hypertension with ulcer and inflammation.

Keep Your Documentation Solid

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.”