How To Use CPT Code 36475

CPT 36475 is a code used for endovenous ablation therapy of incompetent vein in an extremity using radiofrequency 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 36475 procedures.

1. What is CPT 36475?

CPT 36475 is a medical billing code used to describe the endovenous ablation therapy of an incompetent vein in an extremity using radiofrequency. This code is specifically used for the first vein treated in the procedure. Endovenous ablation therapy is a minimally invasive treatment for venous insufficiency, which is a condition where the veins in the extremities, usually the legs, do not function properly, leading to various symptoms such as pain, swelling, and skin changes.

2. 36475 CPT code description

The official description of CPT code 36475 is: “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated.”

3. Procedure

The 36475 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, which is then removed.
5. The radiofrequency probe is passed to the target location through the inside of the sheath.
6. Radiofrequency energy is used to ablate the veins, destroying the vein wall and sealing it shut.
7. The probe and sheath are pulled back and removed.
8. The puncture site is irrigated and pressure is applied to control bleeding.

4. Qualifying circumstances

Patients eligible to receive CPT code 36475 services are those diagnosed with venous insufficiency in an extremity, typically the lower extremities. This condition is characterized by the failure of one-way valves in the veins, leading to the backward flow or reflux of blood. Symptoms of venous insufficiency include swelling, pain, changes in skin color and texture, and even ulcers in the affected region. Endovenous ablation therapy using radiofrequency is an effective treatment method for patients with this condition.

5. When to use CPT code 36475

It is appropriate to bill the 36475 CPT code when a provider performs endovenous ablation therapy of an incompetent vein in an extremity using radiofrequency for the first vein treated. This code should not be used for additional veins treated during the same procedure; instead, use the add-on code +36476 for each additional vein treated.

6. Documentation requirements

To support a claim for CPT 36475, the following information should be documented:

• Patient’s medical history and diagnosis of venous insufficiency in an extremity.
• Details of the procedure, including the use of radiofrequency energy and the specific vein treated.
• Ultrasound guidance and monitoring used during the procedure.
• Post-procedure care, including irrigation of the puncture site and pressure application to control bleeding.
• Any complications or adverse events that occurred during the procedure.

7. Billing guidelines

When billing for CPT code 36475, keep in mind the following guidelines and rules:

• Use this code only for the first vein ablation; for additional veins, use add-on code +36476.
• Do not report ultrasound guidance separately, as it is included in the code description.
• If the provider performs endovenous ablation therapy and sclerotherapy for a single vein, use CPT 36475 for the ablation and CPT 36470 for the injection of sclerosant in a single incompetent vein other than telangiectasia. Sclerotherapy can be reported separately.

8. Historical information

CPT 36475 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 36475

Five similar codes to CPT 36475 and how they differentiate are:

1. CPT 36476: This add-on code is used for each additional vein treated during the same endovenous ablation therapy procedure using radiofrequency.
2. CPT 36470: This code is used for the injection of sclerosant in a single incompetent vein other than telangiectasia, which may be performed in conjunction with endovenous ablation therapy.
3. CPT 36471: This code is used for the injection of sclerosant in multiple incompetent veins other than telangiectasia.
4. CPT 36478: This code is used for endovenous ablation therapy of incompetent vein, extremity, using laser energy for the first vein treated.
5. CPT 36479: This add-on code is used for each additional vein treated during the same endovenous ablation therapy procedure using laser energy.

10. Examples

Here are 10 detailed examples of CPT code 36475 procedures:

1. A patient with venous insufficiency in the left leg undergoes endovenous ablation therapy using radiofrequency for the first vein treated.
2. A patient with a history of deep vein thrombosis in the right leg receives endovenous ablation therapy using radiofrequency for the first vein treated.
3. A patient with chronic venous insufficiency in both legs undergoes endovenous ablation therapy using radiofrequency for the first vein treated in the right leg.
4. A patient with varicose veins in the left leg receives endovenous ablation therapy using radiofrequency for the first vein treated.
5. A patient with venous ulcers in the right leg undergoes endovenous ablation therapy using radiofrequency for the first vein treated.
6. A patient with a history of multiple episodes of superficial vein thrombosis in the left leg receives endovenous ablation therapy using radiofrequency for the first vein treated.
7. A patient with chronic venous insufficiency and skin changes in the right leg undergoes endovenous ablation therapy using radiofrequency for the first vein treated.
8. A patient with a history of recurrent varicose veins in the left leg receives endovenous ablation therapy using radiofrequency for the first vein treated.
9. A patient with venous insufficiency and leg swelling in the right leg undergoes endovenous ablation therapy using radiofrequency for the first vein treated.
10. A patient with a history of failed conservative management for venous insufficiency in the left leg receives endovenous ablation therapy using radiofrequency for the first vein treated.