General Surgery Coding Alert

Vein ligation and stripping procedures often are rejected by payers, including Medicare, as cosmetic. But by correctly using diagnostic codes to show medical necessity and adding the right modifier, surgeons can minimize denials.

Surgical ligation and stripping is done to the main trunk of the superficial saphenous vein. If the long saphenous vein is to be removed, an incision (1-2 inches) is made in the groin. The superficial saphenous vein is located and a special surgical instrument is then fed down the vein to just above the knee on the inner thigh. An excision is made at the ending point (usually 1 inch long). If the short saphenous vein is to be removed, an incision (1-2 inches) is made behind the knee. The superficial saphenous vein is located and a special surgical instrument is then fed down the vein to just above the ankle. An incision is made at the ending point (usually 1 inch long). In both cases, the vein is then excised through these incisions.

The removal of vein clusters is performed via a small incision in the skin over localized areas of superficial varicose veins along the leg. These veins are then isolated and dissected free of neighboring tissue, and tied with sutures or stripped out bluntly.

Accurately Coding the Procedures

CPT lists two codes for vein stripping:

37720ligation and division and complete stripping of long or short saphenous veins, and
37730ligation and division and complete stripping of long and short saphenous veins.

The difference between the two is important: 37720 should be used when either the long or short vein is stripped, while 37730 is used if both long and short veins are removed.

This small difference takes on greater significance when the surgeon also removes varicose vein clusters, which are secondary vessels off the saphenous veins (37785, ligation, division and/or excision of recurrent or secondary varicose veins [clusters], one leg). Although the national Correct Coding Initiative (CCI) bundles 37785 into both 37730 and 37720, modifier -59 (distinct procedural service) may be attached to 37720 (but not 37730), overriding the CCI edit and allowing the surgeon to get paid for performing the procedure.

Note: 37720 has a CCI indicator of 1, which means that attaching the -59 modifier is permitted; 37730s indicator 0, means that use of -59 to override the edit is prohibited.

Therefore, if a surgeon removes either the long or short saphenous vein and also takes out varicose vein clusters, both procedures may be billed (with modifier -59 attached to the saphenous vein removal to indicate it was performed on a separate system on the same leg). But if both the long and short saphenous veins are taken out, the removal of both saphenous veins is bundled to the excision of the vein clusters.

In other words, if the operative report states that there is complete vein stripping of the greater and lesser saphenous veins on the left leg with excision of secondary clusters on the same leg, the surgeon can bill only 37785 because this code includes 37730, says Terry Fletcher, BS, CPC, CCS-P, a coding and reimbursement specialist in Laguna Beach, Calif.

If the operative report states that 37730 was performed on the left leg and 37785 was performed on the right leg, both procedures may be billed with modifier -LT (left side) attached to 37730 and modifier -RT (right side) appended to 37785.

Medical Necessity Must Be Indicated

Fletcher notes that some carriers continue to bundle 37785 to 37720 and adds that modifier -59 is not always recognized by third-party payers. In addition, surgeons should get their Medicare patients to sign a waiver stating that they may be responsible for payment because many Medicare carriers will not pay for the procedure if they believe it was performed for cosmetic reasons.

According to South Carolinas Medicare carrier, Palmetto Government Benefits Administrators, services must be determined to be reasonable and necessary for diagnosis or treatment of illness or injury in order for Medicare payment to be allowed. 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 ... operative and sclerotherapy of the lower extremities is covered by Medicare when the therapy is determined to be medically reasonable and necessary. Therapy provided purely for cosmetic purposes, and the expenses incurred in connection with such cosmetic surgery, is denied ...

According to Medicodes 1999 Coding Illustrated: Cardiovascular and Respiratory, the following ICD-9 codes may be used in conjunction with 37720 and 37730:

454.0varicose veins of lower extremities with ulcer;
454.1with inflammation;
454.2with ulcer and inflammation;
454.9without mention of ulcer or inflammation;
459.81unspecified venous insufficiency, peripheral;
707.1ulcer of lower limbs, except decubitus;
729.82cramp of limb.

For 37785, the following diagnosis codes may be used: 454.1, 454.9 and 459.81.

Note: Your carrier may not recognize some of these codes as providing medical necessity for these procedures. Check with your carrier and, if necessary, have your patient sign a waiver.