How To Use CPT Code 36478

CPT 36478 is a code used for endovenous ablation therapy of incompetent vein in an extremity using laser for the first vein treated. 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 36478 procedures.

1. What is CPT 36478?

CPT 36478 is a medical billing code used to describe the endovenous ablation therapy of an incompetent vein in an extremity using laser for the first vein treated. This procedure is performed to treat varicose veins and venous insufficiency in patients, helping to alleviate symptoms and improve overall vein health.

2. 36478 CPT code description

The official description of CPT code 36478 is: “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated.”

3. Procedure

The 36478 procedure involves the following steps:

  1. The patient is appropriately prepped and anesthetized.
  2. A small opening is created in the skin over the affected vein.
  3. A guidewire is inserted under ultrasound guidance and passed through the vein to the target location.
  4. A hollow tube, known as a sheath, is inserted over the guidewire, and the guidewire is removed.
  5. The laser ablation catheter is passed to the target location through the inside of the sheath.
  6. Laser energy is used to ablate the veins, destroying the vein wall and sealing it off.
  7. The laser and sheath are pulled back, and the puncture site is irrigated and pressure is applied to control bleeding.

4. Qualifying circumstances

Patients eligible to receive CPT code 36478 services are those diagnosed with venous insufficiency or varicose veins in an extremity, causing symptoms such as pain, swelling, heaviness, skin discoloration, or ulceration. The procedure is typically recommended for patients who have not responded to conservative treatments, such as compression stockings or lifestyle changes.

5. When to use CPT code 36478

It is appropriate to bill the 36478 CPT code when a provider performs endovenous ablation therapy using laser for the first vein treated in an extremity. This code should be used for the initial vein treated during the procedure, with additional veins billed using the add-on code +36479.

6. Documentation requirements

To support a claim for CPT 36478, the following information should be documented:

  • Patient’s medical history and diagnosis of venous insufficiency or varicose veins
  • Conservative treatments attempted and their outcomes
  • Details of the procedure, including the vein treated, the use of laser ablation, and any imaging guidance or monitoring used
  • Post-procedure care and follow-up instructions

7. Billing guidelines

When billing for CPT code 36478, keep in mind the following guidelines:

  • Use this code only for the first vein ablation; for additional veins, use the add-on code +36479.
  • Do not report ultrasound guidance separately, as it is included in the code description.
  • Sclerotherapy may be reported separately if performed in conjunction with endovenous ablation therapy.

8. Historical information

CPT 36478 was added to the Current Procedural Terminology system on January 1, 2005. There have been no updates to the code since its addition.

9. Similar codes to CPT 36478

Five similar codes to CPT 36478 and how they differentiate are:

  • CPT 36479: This add-on code is used for endovenous ablation therapy of incompetent veins using laser for each additional vein treated during the same session.
  • CPT 36465: This code is used for endovenous ablation therapy of incompetent veins using radiofrequency energy for the first vein treated.
  • CPT 36466: This add-on code is used for endovenous ablation therapy of incompetent veins using radiofrequency energy for each additional vein treated during the same session.
  • CPT 36470: This code is used for injection of sclerosant into a single incompetent vein other than telangiectasia.
  • CPT 36471: This code is used for injection of sclerosant into multiple incompetent veins other than telangiectasia during the same session.

10. Examples

Here are 10 detailed examples of CPT code 36478 procedures:

  1. A patient with venous insufficiency and varicose veins in the left leg undergoes endovenous laser ablation therapy for the first vein treated.
  2. A patient with a history of leg pain and swelling is diagnosed with venous insufficiency and undergoes endovenous laser ablation therapy for the first vein treated in the right leg.
  3. A patient with skin discoloration and ulceration due to venous insufficiency undergoes endovenous laser ablation therapy for the first vein treated in the left leg.
  4. A patient with a history of failed conservative treatments for varicose veins undergoes endovenous laser ablation therapy for the first vein treated in the right leg.
  5. A patient with venous insufficiency and varicose veins in both legs undergoes endovenous laser ablation therapy for the first vein treated in each leg during separate sessions.
  6. A patient with a history of leg pain and heaviness due to venous insufficiency undergoes endovenous laser ablation therapy for the first vein treated in the left leg.
  7. A patient with a history of leg swelling and skin discoloration due to venous insufficiency undergoes endovenous laser ablation therapy for the first vein treated in the right leg.
  8. A patient with a history of leg pain and varicose veins undergoes endovenous laser ablation therapy for the first vein treated in the left leg, followed by sclerotherapy for additional veins.
  9. A patient with a history of leg swelling and varicose veins undergoes endovenous laser ablation therapy for the first vein treated in the right leg, followed by sclerotherapy for additional veins.
  10. A patient with a history of leg pain, swelling, and skin discoloration due to venous insufficiency undergoes endovenous laser ablation therapy for the first vein treated in the left leg, followed by sclerotherapy for additional veins.

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