How To Use CPT Code 36465

CPT 36465 is a code used for the injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate in a single incompetent extremity truncal vein. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 36465 procedures.

1. What is CPT 36465?

CPT 36465 is a medical billing code used to describe a specific procedure involving the injection of a non-compounded foam sclerosant into a single incompetent truncal vein of the extremity, with the use of ultrasound compression maneuvers to guide the dispersion of the injectate. This code is commonly used for the treatment of varicose veins.

2. 36465 CPT code description

The official description of CPT code 36465 is: “Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)”.

3. Procedure

The 36465 procedure involves the following steps:

  1. The patient is appropriately prepped for the procedure.
  2. The provider uses an ultrasound probe to detect the diseased vein.
  3. After identification of the diseased vein, the provider inserts a syringe filled with a foam sclerosing solution into the vein.
  4. The provider presses on the area being treated with the ultrasound probe to guide the dispersion of the foam.
  5. The solution causes the vein’s walls to collapse.
  6. After injecting the solution, the provider removes the needle and applies pressure to stop bleeding.

4. Qualifying circumstances

Patients eligible to receive CPT code 36465 services are those who have been diagnosed with an incompetent truncal vein in the extremity, such as the great saphenous vein or accessory saphenous vein. These patients typically present with symptoms of varicose veins, including pain, swelling, and skin changes. The provider must determine that the use of non-compounded foam sclerosant with ultrasound compression maneuvers is the most appropriate treatment option for the patient’s condition.

5. When to use CPT code 36465

It is appropriate to bill the 36465 CPT code when the provider performs the injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate in a single incompetent extremity truncal vein. This code should be used only for the treatment of a single truncal vein of the extremity and not for multiple veins or other types of veins.

6. Documentation requirements

To support a claim for CPT 36465, the following information needs to be documented:

  • Patient’s medical history and symptoms related to the incompetent truncal vein.
  • Physical examination findings, including the presence of varicose veins and any associated complications.
  • Diagnostic imaging results, such as ultrasound, confirming the presence of an incompetent truncal vein.
  • Provider’s decision to use non-compounded foam sclerosant with ultrasound compression maneuvers as the most appropriate treatment option.
  • Detailed description of the procedure, including the steps taken, the amount of sclerosant used, and the specific vein treated.
  • Post-procedure assessment, including any complications or adverse reactions.
  • Follow-up care plan, including any additional treatments or interventions needed.

7. Billing guidelines

When billing for CPT code 36465, it is important to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 36465 include:

  • Ensure that the documentation supports the use of CPT 36465, as described in the documentation requirements section.
  • Bill CPT 36465 only for the treatment of a single incompetent truncal vein of the extremity, not for multiple veins or other types of veins.
  • Be aware of any payer-specific guidelines or requirements related to billing for CPT 36465.
  • For injection of non-compounded foam sclerosant of multiple incompetent veins, use CPT code 36466 instead.

8. Historical information

CPT 36465 was added to the Current Procedural Terminology system on January 1, 2018. There have been no updates to the code since its addition.

9. Similar codes to CPT 36465

Five similar codes to CPT 36465 and how they differentiate from CPT 36465 are:

  • CPT 36466: This code is used for the injection of non-compounded foam sclerosant of multiple incompetent veins, as opposed to a single vein in CPT 36465.
  • CPT 36468: This code is used for the treatment of spider veins by injection of sclerosant (solution), which is different from the foam sclerosant used in CPT 36465.
  • CPT 36470 and 36471: These codes are used for the treatment of veins other than spider veins by injection of sclerosant (solution), with 36470 for a single vein and 36471 for multiple veins. They differ from CPT 36465, which uses foam sclerosant.
  • CPT 36473 and +36474: These codes are used for mechanochemical endovenous ablation, a different treatment method than the foam sclerosant injection in CPT 36465.

10. Examples

Here are 10 detailed examples of CPT code 36465 procedures:

  1. A 45-year-old female with painful, swollen varicose veins in her left great saphenous vein undergoes CPT 36465 treatment.
  2. A 60-year-old male with an incompetent accessory saphenous vein and skin changes in his right leg receives CPT 36465 treatment.
  3. A 55-year-old female with a history of deep vein thrombosis and an incompetent great saphenous vein in her left leg undergoes CPT 36465 treatment.
  4. A 50-year-old male with chronic venous insufficiency and an incompetent right great saphenous vein receives CPT 36465 treatment.
  5. A 65-year-old female with a non-healing venous ulcer and an incompetent left accessory saphenous vein undergoes CPT 36465 treatment.
  6. A 40-year-old male with a history of multiple superficial thrombophlebitis episodes and an incompetent right great saphenous vein receives CPT 36465 treatment.
  7. A 70-year-old female with a painful, swollen varicose vein in her left great saphenous vein undergoes CPT 36465 treatment.
  8. A 48-year-old male with an incompetent accessory saphenous vein and recurrent leg swelling in his right leg receives CPT 36465 treatment.
  9. A 52-year-old female with a history of venous insufficiency and an incompetent great saphenous vein in her left leg undergoes CPT 36465 treatment.
  10. A 57-year-old male with chronic venous insufficiency and an incompetent right accessory saphenous vein receives CPT 36465 treatment.

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