General Surgery Coding Alert

What's Involved?

CPT contains two primary codes to describe surgical ligation and stripping of veins:

In addition, the surgeon may also remove varicose vein clusters, as described by 37785 (Ligation, division, and/or excision of recurrent or secondary varicose veins [clusters], one leg), during the same operative session.

Note: See CPT for a complete list of surgical ligation and vein stripping codes.

A surgeon performs procedures 37720 and 37730 on the main trunk of the superficial saphenous vein, either by making an incision at the groin (long saphenous vein) or behind the knee (short saphenous vein), depending on which vein is to be removed. In both cases, the targeted vein is located and excised through a separate incision below the point of entry.

Code 37720 is used if either the long or short saphenous veins are targeted, while 37730 is appropriate if both the long and short saphenous veins are removed.

The surgeon removes vein clusters (37785) by making a small incision over localized areas of superficial varicose veins along the leg. The veins are then isolated and dissected free of neighboring tissue and, finally, either tied with sutures or stripped out bluntly.

CCI considers 37785 mutually exclusive of both 37730 and 37720. The edits include a CCI indicator of "1," however, meaning that modifier -59 (Distinct procedural service) may be attached to 37785 under certain circumstances (e.g., the procedures are performed at distinct anatomical sites) to override the edit.

For example, if a surgeon removes both the long and short saphenous vein and also removes varicose vein clusters at a different location on the same leg, both procedures may be billed if modifier -59 is appended to 37785 to indicate a separate anatomic location.

In a second example, the surgeon removes the short saphenous veins in the right leg, along with varicose vein clusters at the same location. In this case, only the more extensive procedure (37720) may be reported because the criteria for appending modifier -59 (and therefore for separate reporting) have not been met.

Note: Code 37780 (Ligation and division of short saphenous vein at saphenopopliteal junction) is similarly bundled to 37720, 37730, 37735 (Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer ...) and 37785, and may be separately reported under situations identical to those described above.

For example, if the surgeon removes long and short saphenous veins from the right leg and varicose vein clusters from the left leg, he or she may report both procedures (37785 and 37730) with modifier -59 appended to 37730 to indicate a different location. And modifiers -RT (Right side) and -LT (Left side) may be appended to 37785 and 37730, respectively, to differentiate the procedures further and substantiate the claim of separate anatomic locations.

If the surgeon performs 37720 or 37730 on both legs, append modifier -50 (Bilateral procedure) to the appropriate procedure code. Medicare and other payers will generally reimburse for bilateral procedures at 150 percent of the regular fee schedule rate.

Note, however, that because the descriptor for 37785 specifically states "one leg," if 37785 is performed bilaterally, modifier -50 should not be appended. Rather, two units of 37785 should be reported.

Seal the Deal: Medical Necessity

Most important, to ensure payment for surgical ligation and vein stripping, surgeons must demonstrate medical necessity: Medicare will only reimburse for services determined "to be reasonable and necessary for diagnosis or treatment of illness or injury."

For example, according to Palmetto Government Benefits Administrators, South Carolina's Medicare carrier, "Appropriate indicators of reasonable and necessary treatment of varicose veins would be a documented history of significant persistent pain despite a trial of compression, and/or a history of severe venous insufficiency with recurrent ulcerations ... Therapy provided purely for cosmetic purposes, and the expenses incurred in connection with such cosmetic surgery, is denied ..."

Individual carriers maintain lists of diagnoses they will accept to demonstrate medical necessity. A partial list may include any of the following for 37720 and 37730: