How To Use CPT Code 36476

CPT 36476 describes the endovenous ablation therapy of incompetent vein in an extremity, including all imaging guidance and monitoring. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 36476?

CPT 36476 can be used to describe the endovenous ablation therapy of an incompetent vein in an extremity. This procedure involves the use of radiofrequency energy to destroy the wall of the diseased vein, and it is performed in conjunction with the ablation of the initial vein. It is important to note that CPT 36476 is an add-on code and should be reported with the appropriate primary code, CPT 36475.

2. Official Description

The official description of CPT code 36476 is: ‘Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).’ It is important to remember that CPT 36476 should not be reported more than once per extremity and should not be reported with certain other codes in the same surgical field.

3. Procedure

1. In this procedure, the provider inserts a specially designed radiofrequency probe through the skin to reach the diseased vein in the extremity.
2. The provider creates an additional small opening in the skin over the affected vein and inserts a guide wire under ultrasound guidance.
3. A hollow tube, known as a sheath, is then inserted over the guide wire, and the guide wire is removed.
4. The provider passes the radiofrequency probe through the sheath to the target location and uses radiofrequency energy to ablate the additional veins.
5. After completing the procedure, the provider removes the probe and sheath, irrigates the puncture site, and applies pressure to control bleeding.

4. Qualifying circumstances

CPT 36476 is used for patients with venous incompetency, which occurs when the valves in the leg veins are not working effectively. This condition can lead to swelling, pain, changes in skin color and texture, and even ulcers. The procedure is performed on subsequent veins in the same extremity and requires separate access sites. It is important to note that CPT 36476 should not be reported with certain other codes in the same surgical field.

5. When to use CPT code 36476

CPT code 36476 should be used when the provider performs endovenous ablation therapy on subsequent veins in a single extremity, using separate access sites. It is important to report this code in conjunction with the primary code, CPT 36475, which represents the ablation of the initial vein. CPT 36476 should not be reported more than once per extremity and should not be reported with certain other codes in the same surgical field.

6. Documentation requirements

To support a claim for CPT 36476, the provider must document the following information:

• Indication for the procedure and the need for endovenous ablation therapy
• Details of the procedure, including the use of radiofrequency energy and the number of veins treated
• Date of the procedure and the specific extremity treated
• Documentation of all imaging guidance and monitoring performed
• Any complications or adverse events that occurred during or after the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 36476, it is important to ensure that the procedure is performed in conjunction with the primary code, CPT 36475. This is an add-on code, and payers will not reimburse for CPT 36476 without an appropriate primary code. Additionally, CPT 36476 should not be reported with certain other codes in the same surgical field. It is important to review the explanation of benefits (EOB) carefully to ensure proper reimbursement for add-on codes. Multiple procedure discounts should not be applied to add-on codes unless specified in a contract.

8. Historical information

CPT 36476 was added to the Current Procedural Terminology system on January 1, 2005. On January 1, 2017, the code description was updated to specify the treatment of second and subsequent veins in a single extremity, each through separate access sites.

9. Examples

1. A provider performs endovenous ablation therapy on the second and third veins in a patient’s right leg, using separate access sites.
2. During a single session, a provider performs endovenous ablation therapy on the fourth and fifth veins in a patient’s left leg, using separate access sites.
3. A patient undergoes endovenous ablation therapy on the second vein in their right leg, followed by treatment of the third and fourth veins in a separate session.
4. A provider performs endovenous ablation therapy on the second and third veins in a patient’s left leg, using separate access sites, during a single session.