General Surgery Coding Alert

For example, Regence Blue Cross/Blue Shield of Oregon guidelines specify that "Cosmetic or potentially cosmetic procedures (e.g., breast surgery, rhinoplasty, septorhinoplasty, varicose vein surgery/sclerotherapy, male gynecomastia surgery)" require preauthorization. The policy notes that varicose veins, for instance, can usually be treated with less radical options than surgery, but that when more conservative treatment measures fail, surgery is a viable option.

Specifically, the Regence policy states:

Vein ligation and division, vein ligation and division and complete stripping, and endoluminal radiofrequency ablation of the greater saphenous vein, as an alternative to saphenous vein ligation and stripping, may be medically necessary when all of the following criteria (1-3) are met:

1. One of the following indications (A-E) is present:
A. Persistent symptoms interfering with activities of daily living despite non-surgical management. Symptoms include aching, cramping, burning, itching, and/or swelling during activity or after prolonged standing
B. Significant attacks of superficial phlebitis
C. Hemorrhage from ruptured varix
D. Ulceration from venous stasis (usually in conjunction with deep venous insufficiency) where incompetent varices are a contributing factor
E. Symptomatic incompetence of greater or lesser saphenous veins (symptoms as listed in "A" above)

2. A trial of six weeks of nonoperative management has failed. Nonoperative management includes walking, avoidance of prolonged sitting, frequent elevation of affected leg(s) and use of compression stockings.

3. All significant abnormalities are addressed as the outcomes depend on the thoroughness of the procedure.

Surgeons contemplating vein ligation surgery should contact the individual payer to see if similar guidelines apply and, if so, take steps to demonstrate that all criteria for reimbursing the procedures have been properly met prior to filing a payment claim.