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Scenario Week of July 15, 2011:
View Current Scenario

Indications: The patient is a 53-year-old female who complains of varicose veins associated with ongoing pain, increased swelling, and frequent leg cramps at night. She has failed conservative treatment of the use of compression stockings for about 7 months.

Informed Consent: The risks and benefits of the procedure were previously discussed with the patient and she has elected to proceed. The signed consent is in the patient’s chart.

Diagnostic Ultrasound: Ultrasound examination shows the common femoral vein[s] and the popliteal vein[s] to be compressible and shows no evidence of DVT. All deep veins are open. All veins treated previously with thermal ablation continue to remain closed. Venous duplex examination of the lower extremity veins show reflux in medial inner calf as well as the anterior area of the patient’s lower left leg. Diameters of veins with reflux are found to be 4 to 5 mm.

Approach and Surgical Procedure: The patient was brought in the operating suite and placed on the operating table. Legs were scanned as indicated above using duplex ultrasound to locate the incompetent veins and determine the appropriate sites of injection. The mapped areas were prepped using hydrogen peroxide alcohol. The sclerosant was prepared using the Tessari method and a 1:4 ratio. The vessels were injected at sites along their course. To ensure accurate needle placement and to observe for possible extravasation of the sclerosant, the injections were performed under direct duplex visualization.

Following injection of the veins, the area surrounding the veins was injected with tumescent solution to apply internal compression. Total volume used was less than 50 cc.

The leg was cleaned with hydrogen peroxide and normal saline. A class II compression stocking was donned and postoperative instructions were given. The patient was released in good condition and advised to ambulate for 30 to 45 minutes daily and immediately following today’s procedure.

Sclerosant Used: 3.0 cc Sotradecol 1.0%

How would this scenario be coded using 2011 codes?

The appropriate CPT coding for this procedure would be:

36471 Injection of sclerosing solution; multiple veins, same leg
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT code 36471 is used to report the injection of more than one vein in the same leg; a single vessel is reported with 36470. This is a unilateral service and does not require the addition of a modifier to identify single side or more than one vein. Ultrasonic guidance may be reported in addition to the injection. These two codes do not activate a CCI edit. Because this procedure usually is not done out of medical necessity, the patient may be responsible for charges. Verify with insurance carrier for coverage.

The appropriate ICD-9-CM coding for this procedure would be:

454.8 Varicose veins of lower extremities with other complications

Only the postoperative diagnosis is reported. The index does not list the specific complication of reflux. The varicose veins were not asymptomatic and the other 4th digit classifications identify other complications not identified. The appropriate code for varicose veins with reflux is 454.8.

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