Vein Procedures coding help - Technological advancements

 In the last few years, new and improved treatments for vein diseases have become commonplace for many patients who previously had to suffer the pain and disfigurement of varicose veins and associated venous diagnoses. Vein diseases range from deep venous thrombosis (DVT) to varicose veins, venous rupture, and atherosclerosis (stricture due to plaque buildup inside of the veins).  Therefore, it's important for medical coders to understand the procedures and correct CPT and ICD-9 coding related to varicose veins and similar diagnoses, especially venous ligation, stab phlebectomy, endovenous ablation, vein sclerosing, and miscellaneous vein procedures (e.g., venous ultrasound).  Vein basics Veins carry de-oxygenated blood to the heart, while arteries carry re-oxygenated blood from the heart. There are superficial and subcutaneous veins; deep veins communicate between both sets. Veins do not accompany an artery. Veins also differ from arteries in that they:  

1. • handle a larger capacity of blood volume back to the heart 
2. • exist in greater numbers within the body 
3. • have thinner walls made up of three layers  
4. • have valves to prevent backflow or backward circulation

 It is when the valves inside these veins stop working correctly that the blood within them backflows and causes the vein to enlarge and pool with stagnant blood. This is called a varicose vein. It is this reflux that causes the enlargement of the vein, often accompanied by pain. In addition to the pain, the enlargement can cause venous stasis ulcers and venous thrombosis. A venous stasis ulcer is an open wound, resulting from the pooling of non-oxygenated blood, which causes the skin/tissue to become thin and break open. Venous thrombosis is the pooling of nonoxygenated blood (and sometimes clotted blood) within the vein. Sometimes these clotted thromboli travel back toward the heart or lungs.   There are many different causes of varicose veins. The most common factor is damaged/defective valves within the vein. Other factors contributing to the cause and severity of the condition include pregnancy, obesity, prolonged standing, prior leg surgery, and trauma to the leg, infection.  Likewise, there are many different types of treatment for varicose veins, including:

• conservative (non-surgical) therapy 

• light-based treatments 

• sclerotherapy 

• surgery 

• endovenous procedures

 

 Each of these therapies (and some others) is outlined below along with the accompanying CPT/ICD-9 codes. This is only a brief list. Consult your CPT and ICD-9 references to confirm your code choices. If you come across terminology that you are not familiar with, consult your medical dictionary to clarify the meaning before you code.

Conservative (non-surgical) therapy

Graduated compression hosiery, also known as "ted hose," is one conservative treatment for varicose veins. With graduated compression hosiery, the compression is tightest around the foot, ankle, and lower leg, and decreases in pressure as the stocking goes up around the calf and thigh. The most commonly prescribed form of graduated compression hosiery is the knee-high version. However, if the varicosity is above the knee, there are thigh-high, chap style, and body stocking versions (much like panty-hose). These stockings help prevent pooling of the blood in the lower extremity and promote normal blood flow back up the leg.    Compression hosiery is available in many different compressions. The physician will prescribe the best compression for the patient. Although some compression hosiery is available at local drug stores, some must be ordered from your physician or durable medical equipment supplier. The HCPCS Manual describes the compression types and styles in detail.  HCPCS codes change very often, so consult it prior to deciding upon a code. In addition to compression hosiery, other conservative options include the following:

• Elevating the patient's leg(s) above his or her heart when sitting or relaxing 

• Walking (this stimulates the blood flow to/from the heart) 

• Avoiding alcohol (it causes veins to dilate)  

• Avoiding the crossing of legs/ankles when sitting   

• Taking an hourly walk/stretch when sitting or driving for long periods of time (this allows the muscles to pump blood back out of the deeper vein system)   

• Losing weight, or maintaining the current weight, if the patient is overweight (avoid yo-yo dieting)  

   

Light-based treatments

Lasers and intense-pulsed light treatment (IPLT) are other forms of therapy for reducing redness and spider veins that are in the top layers of the skin. In both cases, the laser or intense light focuses through the skin on the spider vein, causing the blood in the vein to absorb the energy and collapse the vein closed.   Superficial spider veins and redness on the outer layers of the skin do not normally cause any pain; most insurance carriers consider laser or IPLT treatments for these conditions to be cosmetic procedures. CPT does not have many codes for the light-based treatments, so you may have to bill with an unlisted code and denote the services on your claim form, backed up by physician documentation. 

 CPT codes:  17000-17108, 96567, +96570, +96571 96900, 96920-96922, 96999

Duplex ultrasound/doppler exam of the extremities (legs) Duplex or doppler evaluations of the veins in the arms and legs checks for the competency of the valves within the veins, looking for backflow or reflux blood flow within the vein. These scans use a combination of real-time ultrasound and doppler

CPT codes: 93965, 93970, 93971, 76937, 76942, 76000, 76001 76881, 76882    

Intravascular ultrasound 

Intravascular ultrasound may be used during diagnostic evaluation of a noncoronary artery or vein. It may also be used to assess the patency and integrity of the vessel. A needle enters through the skin and goes into a blood vessel, allowing a guide wire to thread through the needle into the blood vessel. After removing the needle, the physician places an intravascular ultrasound catheter over the guide wire. This catheter can obtain images from inside the vessel that the physician uses to assess the area and extent of the disease prior to therapy. This can also help determine the adequacy of current therapy.  The physician then removes the catheter and guide wire.    CPT codes: +37250, +37251, 76937, 76942, 76000, 76001    Sclerotherapy Sclerotherapy is a procedure in which the physician injects a solution (sclerosant) percutaneously through the skin to the vein. This solution causes the vein to seal off, or sclerose/harden, stopping the blood flow through the vein. In some cases a physician will use ultrasound guidance in locating the vein. This is referred to as echoscherotherapy.    

CPT codes:  36468, 36469, 36470, 36471, 76937, 76942, 76000-76003   

Endovenous procedures

Endovenous procedures are less risky than traditional surgical methods of varicose vein treatment. Endovenous therapy uses either a laser or radiofrequency to seal off the vein by use of a catheter. The catheter enters the vein and the heat from the laser or radiofrequency causes the vein to collapse, sealing off the blood flow. This procedure can occur in an outpatient or office-type setting, allowing the patient to recover quickly and resume normal activities.    CPT codes: 36475, +36476, 36478, +36479   

Surgical treatment options 

The traditional surgical-based procedures for varicose veins are the following:

• Surgical ligation. The physician makes an incision close to the vein and ties off of the problematic varicose vein, stopping all blood flow through the vein.   

• Surgical vein stripping. The physician makes an incision near the vein and uses a wire to pull out the problematic vein, then ties off or surgically closes the vein.    

• Phlebectomy, or stab phlebectomy. The physician numbs the area surrounding the veins or vein cluster, incises the area, and uses a small hook to grasp and remove the vein or vein clusters.  

  

These are commonly outpatient procedures, although some vein stripping and ligation procedures require an overnight stay in the hospital. Also, these procedures carry more risk than endovenous procedures. The severity of the varicosity determines whether the patient requires surgery or could be a candidate for phlebectomy or an endovenous procedure.   

CPT codes: 37700, 37718, 37722, 37735, 37760, 37780, 37785 (ligations/stripping) 37765, 37766 (stab phlebectomy)   

Diagnosis Codes for Vein procedures

The ICD-9 codes listed below are most commonly used for the venous procedures outlined above. However, this is not an all-inclusive list, and you will want to look at all 5th digits that may be needed. In addtion, you may want to look at or include other diagnoses with your coding.

• 440.20: Atherosclerosis of native arteries of the extremities, unspecified 

• 451.0-451.2: Phlebitis and thrombophlebitis 

• 453-453.9: Other venous embolism and thrombosis 

• 454.0-454.9: Varicose veins 

• 459.0-459.9: Other disorders of circulatory system (e.g., hemorrhage, ruptured blood vessel)   

• 671.2-671.9: Venous complications in pregnancy 

In closing - if you have questions, please don't hesitate to contact me.  Happy Coding! 

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Using "unlisted" CPT codes... Ideas to consider...

Do you have trouble deciding if and or when to use an unlisted codes vs/using a CPT code that "is close to" what you want. I've tried to give some insight into what I think is appropriate usage of the unlisted CPT codes and how to report with the insurance payers...

When a provider performs a procedure, or provides a service, that a coder cannot find a specific CPT® code to accurately reflect that specific procedure or service, a coder may report unlisted codes, which are included throughout each section and subsection of the CPT Manual and usually end in “99”. (e.g., code 59899 in the maternity care and delivery section).

Physicians sometimes perform procedures that fall into this category due to a patient’s altered anatomy, a trauma, burn(s), or some other medical reason are not accurately captured in standard listed CPT codes.

Coders should only report unlisted codes for a test or procedure as a last resort. This does not mean you should never use them. But make sure you’ve done your “due diligence” to investigate and determine that there is no other code that more appropriately reflects the procedure or service.

This is especially important for surgical coders and billers to understand, as CMS does not assign any Relative Value Units (RVU's) to unlisted codes. Many of the unlisted CPT codes are grouped to ambulatory payment classifications with little or no reimbursement.

It may be tempting to report a code that is a close description of what the physician documented. However, just because you identify a code that closely matches the procedure or service does not mean it is the correct choice.

Note that when reporting unlisted codes, check to make sure that you don’t overlook reporting an appropriate category III code. You may discover that there is a Category III code for emerging technology that you can include with your unlisted code.

Be sure to carefully read what is actually in your physician documentation or operative report. Don’t just assign codes from the operative report headings; review the entire operative record. You may discover that the physician truly performed a procedure for which there is a listed CPT code, and you simply need to append a modifier (e.g., modifier -52 for a reduced service, modifier -53 for a discontinued service).

If there are additional procedures performed in the same operative session, for which specified CPT codes are appropriate, also include those codes on your claim

The CPT Manual also includes unlisted codes for evaluation and management (E/M) services. Providers may use these unlisted E/M codes for services such as an intra-operative consultation between surgeons and physicians in the operative suite or giving medical clearance for athletic competitions or travel to foreign countries.

The next issue that you will be confronted with, is determining the appropriate amount to charge for the unlisted service. Discuss with your physician the complexity of the service, the amount of time the provider spent rendering the service, and the equipment or supplies used. I have also looked at the RVU amount on those procedures that are 'close' but not an exact match, in arriving at what is a 'fair' RVU or chargeable amount for the unlisted procedure. Put all these factors together to arrive at a dollar amount to bill to the insurance carriers.

When submitting claims that include unlisted codes it is very common for insurance carriers or third-party payers to respond with a denial of payment. CMS and most private payers will edit out the claim from further processing until you send them additional supporting documentation (e.g., the operative note, clinical study references from specialty organizations, a letter detailing medical necessity to support the claim).

Once you receive the electronic denial from the payer requesting supporting documentation, respond back to them by sending a cover letter with your documentation describing the unlisted procedure completely and concisely. Include a copy of the CMS 1500 or UB claim form with the unlisted CPT code, and diagnosis code(s), a copy of the operative or procedure record and path report if appropriate.

Ask the carrier to adjudicate your claim within a standard time frame (e.g., four weeks). If you do not hear from the payer within that requested time, follow-up again with the payer and inquire if they received your claim, If so, ask when they will have the claim processed and payment submitted to you. If not, ask if you can expedite the claim and forward via fax or secure e-mail.

In closing, just realize that CPT has included these 'unlisted' codes for coders to use. Don't avoid using them, or use them when you look at an operative report and think it's 'too hard' to code... just use unlisted codes wisely! You'll be surprised at how successful reimbursement can be when you put all the factors together.