How To Use CPT Code 36479

CPT 36479 describes the endovenous ablation therapy of incompetent vein in a single 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 36479?

CPT 36479 can be used to describe the endovenous ablation therapy of an incompetent vein in a single extremity. This procedure involves the use of laser energy to destroy the wall of the diseased vein, sealing it off. It is performed when there is a failure of the venous wall and/or valves in the leg veins, resulting in venous insufficiency and varicose veins. The procedure includes all imaging guidance and monitoring necessary for the treatment.

2. Official Description

The official description of CPT code 36479 is: ‘Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).’ This code should be used in conjunction with CPT code 36478 for the first vein treated.

3. Procedure

1. The provider creates a small opening in the skin over the affected vein.
2. Under ultrasound guidance, a guidewire is inserted and passed through the vein to the target location.
3. A hollow tube, known as a sheath, is inserted over the guidewire.
4. The guidewire is removed, and the laser ablation catheter is passed through the sheath to the target location.
5. The provider uses laser energy to ablate the veins, sealing them off.
6. After the procedure is complete, the provider removes the catheter and sheath, irrigates the puncture site, and applies pressure to control bleeding.

4. Qualifying circumstances

CPT 36479 is used for patients with incompetent veins in a single extremity that require endovenous ablation therapy. This condition occurs when the venous wall and/or valves in the leg veins are not working effectively, leading to venous insufficiency and varicose veins. The procedure is performed percutaneously using laser energy to ablate the veins. It is important to note that CPT 36479 should not be reported more than once per extremity and should not be reported with certain other codes in the same surgical field.

5. When to use CPT code 36479

CPT code 36479 should be used when the provider performs endovenous ablation therapy on subsequent veins in a single extremity during the same session as the ablation of the initial vein. It is important to report this code in addition to the primary procedure code, CPT 36478, for the first vein treated. This code should not be reported more than once per extremity.

6. Documentation requirements

To support a claim for CPT 36479, the provider must document the following information:

• Identification of the specific vein(s) treated
• Details of the endovenous ablation therapy procedure, including the use of laser energy
• Documentation of all imaging guidance and monitoring performed
• Date of the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 36479, ensure that the procedure meets the criteria for endovenous ablation therapy of incompetent vein in a single extremity. It is important to use the appropriate primary procedure code, CPT 36478, for the first vein treated. Do not report CPT 36479 more than once per extremity. Additionally, be aware of the codes that should not be reported in conjunction with CPT 36479 in the same surgical field. Always review the explanation of benefits (EOB) carefully to ensure proper reimbursement.

8. Historical information

CPT 36479 was added to the Current Procedural Terminology system on January 1, 2005. It underwent a code change on January 1, 2017, with the description updated to include the treatment of second and subsequent veins in a single extremity.

9. Examples

1. A patient undergoes endovenous ablation therapy of an incompetent vein in their right leg, with subsequent veins treated in the same session.
2. A provider performs endovenous ablation therapy on multiple incompetent veins in a patient’s left leg during a single procedure.
3. An individual receives endovenous ablation therapy for varicose veins in their right leg, with separate access sites used for each treated vein.
4. A provider performs endovenous ablation therapy on an incompetent vein in a patient’s left leg, followed by treatment of additional veins in the same extremity.
5. A patient undergoes endovenous ablation therapy for venous insufficiency in their right leg, with all imaging guidance and monitoring included in the procedure.
6. An individual receives endovenous ablation therapy for varicose veins in their left leg, with laser energy used to ablate the veins.
7. A provider performs endovenous ablation therapy on multiple incompetent veins in a patient’s right leg, using separate access sites for each treated vein.
8. An individual undergoes endovenous ablation therapy for venous insufficiency in their left leg, with all imaging guidance and monitoring performed during the procedure.