Endovenous Ablation: Varicose Veins
3647836479wRVU: 2.58 — Endovenous ablation therapy, laser, second or subsequent incompetent vein, same leg (true CPT add-on to 36478; 2.58 wRVU; report once per extremity regardless of number of additional veins treated — NOT per vein)36476wRVU: 2.58 — Endovenous ablation therapy, radiofrequency, second or subsequent incompetent vein, same leg (true CPT add-on to 36475; 2.58 wRVU; report once per extremity)
Right [left] great saphenous vein reflux with symptomatic varicose veins, CEAP class [C2-C6]
Same
Right [left] great saphenous vein endovenous [laser / radiofrequency] ablation with [phlebectomy / sclerotherapy]
[Attending name], MD/DO
[Tech/nurse name]
Tumescent local anesthesia: [X] mL dilute lidocaine/epinephrine perivenous solution
The patient is a [age]-year-old [male/female] with symptomatic varicose veins secondary to GSV reflux confirmed on duplex ultrasound (reflux duration [X] sec, GSV diameter [X] mm). The risks, benefits, and alternatives were discussed and informed consent was obtained.
The great saphenous vein was identified by ultrasound and accessed at the [knee / mid-thigh]. The [laser / RF catheter] was advanced to [2 cm below the saphenofemoral junction (SFJ)]. Tumescent anesthesia was placed perivenously under ultrasound guidance. Post-ablation duplex confirmed [no flow in the treated segment / SFJ occlusion without deep vein involvement].
The patient was positioned supine with the leg elevated. The leg was prepped and draped. Ultrasound was used to identify the GSV at the [knee / mid-calf]. Access was obtained with a [21-gauge] micropuncture needle under ultrasound guidance. A [5 Fr] sheath was placed and the [laser / ClosureFast RF] catheter was advanced under ultrasound visualization to a position [2 cm below the SFJ].
Tumescent anesthesia ([dilute 0.1% lidocaine with 1:1,000,000 epinephrine, with sodium bicarbonate 10 mEq/L] in normal saline) was infiltrated perivenously along the length of the GSV under ultrasound guidance, providing analgesia and compression of the vein around the catheter.
The [laser (wavelength X nm) / radiofrequency] energy was applied in a slow, controlled pullback from the SFJ to the access point per the manufacturer's protocol. Post-ablation duplex ultrasound confirmed closure of the treated GSV segment with no deep vein extension. [Stab phlebectomy of varicose tributaries was performed through [X] stab incisions.]
Compression dressings were applied. The patient was ambulated immediately.
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The patient was ambulated immediately post-procedure. Compression stockings were applied. Follow-up duplex ultrasound at 72 hours was scheduled to confirm GSV closure and rule out DVT.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** GSV reflux, CEAP class ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** GSV endovenous ablation with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Tumescent local: dilute lidocaine/epinephrine/bicarb perivenous
INDICATIONS: .PTAGE-year-old .PTSEX with symptomatic varicose veins. Duplex: GSV reflux *** sec, *** mm. Consent obtained.
FINDINGS: GSV accessed at ***. Catheter to 2 cm below SFJ. Tumescent placed perivenously. Post-ablation duplex: GSV occluded, no deep vein extension.
PROCEDURE:
Supine, leg elevated. Prepped and draped. Ultrasound access of GSV at ***. 21-gauge micropuncture needle. Sheath placed. *** catheter advanced to 2 cm below SFJ under ultrasound. Tumescent anesthesia (dilute lido/epi/bicarb) perivenous. Energy applied with pullback per protocol. Post-ablation duplex: GSV closed, no DVT. [Stab phlebectomy: *** incisions.] Compression dressing. Patient ambulated.
COMPLICATIONS: None
DISPOSITION: Ambulatory, compression applied. Duplex at 72 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Ultrasound-Guided Foam Sclerotherapy
For residual or tributary varicosities, ultrasound-guided foam sclerotherapy was performed. [Sodium tetradecyl sulfate / polidocanol] foam was prepared and injected under ultrasound guidance into the target varicosities. Manual compression was applied. Compression bandaging applied for 48 hours. Billing: commercially prepared non-compounded foam (Varithena/polidocanol 1%) = CPT 36465 (single incompetent vein, 0-day global) or 36466 (multiple veins, same leg, 0-day global). Compounded or hand-mixed foam = CPT 36470 (single vein) or 36471 (multiple veins, same leg). Select based on the specific product used.
Charting Tips
- Document post-ablation duplex confirming GSV occlusion and absence of deep vein extension. Endothermal heat-induced thrombosis (EHIT) extending into the femoral vein is a recognized complication requiring anticoagulation. Documenting a normal post-procedure duplex protects against delayed DVT claims.
- Document catheter tip position at 2 cm below the SFJ. Placement too close to the SFJ risks thermal injury to the femoral vein; too distal reduces efficacy. The specific measurement should be in the note.
- Record CEAP class pre-operatively. This is required for insurance authorization and establishes medical necessity for thermal ablation over compression therapy alone.
- For stab phlebectomy billing (37765/37766): document the exact number of stab incisions in the operative note. The code tier (10-20 vs. >20 incisions) must be supported by documentation.
- ICD-10: I83.91 (varicose veins, unspecified lower extremity without ulcer or inflammation), I83.10-I83.15 (with inflammation by laterality), I83.20-I83.25 (with both ulcer and inflammation). Use the most specific code matching the documented CEAP class.
Billing Tips
- Radiofrequency ablation: 36475 (first vein, 5.17 wRVU, 0-day global) + 36476 add-on per extremity for additional veins (2.58 wRVU); laser ablation: 36478 (first vein, 5.17 wRVU, 0-day global) + 36479 add-on per extremity (2.58 wRVU). MOCA (mechanochemical, ClariVein): 36473 (first vein, 3.41 wRVU) + 36474 add-on (1.71 wRVU). Cyanoacrylate adhesive (VenaSeal): 36482 (first vein, 3.41 wRVU) + 36483 add-on (1.71 wRVU). wRVU is identical between RF and laser modalities.
- Add-on codes (36476/36479) are reported ONCE per extremity regardless of how many additional veins are treated. If you treat GSV + AASV + SSV in one leg, bill: 36478 (primary) + 36479 (add-on, once). Do NOT bill 36479 twice for the same extremity — that is overbilling. Bilateral procedures are separately billable with -RT/-LT for each limb; each limb gets its own primary + add-on structure.
- Sclerotherapy (36470 single vein, 0.73 wRVU; 36471 multiple veins, same leg, 1.46 wRVU) performed at the same session has different bundling rules by ablation modality: sclerotherapy performed alongside LASER ablation (36478) is bundled per CMS NCCI edit (effective 10/2019) and cannot be separately reported without modifier -59 and documentation of a distinct anatomic site. Sclerotherapy alongside RADIOFREQUENCY ablation (36475) is NOT bundled by NCCI — 36470/36471 can be separately reported with 36475 for residual tributaries.
- Stab phlebectomy of tributary varicosities is separately billable when documented as a distinct procedure: 37765 (10-20 stab incisions, one extremity, 4.68 wRVU, 10-day global) or 37766 (>20 stab incisions, 5.85 wRVU, 10-day global). Note the 10-day global for stab phlebectomy vs. the 0-day global for ablation — they differ. Document the number of stab incisions.
- Global period is 0 days for all endovenous ablation primary codes (36473-36483). Post-procedure duplex surveillance, compression stocking fitting, and follow-up visits are separately billable with standard E&M codes.
- Medical necessity documentation: payer coverage policies typically require clinical CEAP class ≥C3, failed conservative therapy (compression per payer policy, typically 6-12 weeks — not universally 12 weeks; verify payer LCD), and duplex confirmation of reflux >0.5 seconds in the superficial venous system. Document all three before submission.
- Duplex ultrasound for vein mapping: 93971 (unilateral or limited extremity duplex, 0.44 wRVU) is separately billable at a prior visit for mapping. Intraoperative duplex guidance is bundled into ablation codes.
General coding reference. Verify with your institution’s billing department before submitting claims.