Description
Documentation will be reviewed to determine if claims for Endovenous Radiofrequency Ablation (ERFA) and Endovenous Laser Treatment (EVLT) for Lower Extremity Varicose Veins meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
Affected Code(s)
36475, 36476, 36478, 36479, 76937
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Ch 12, §40.6 Claims for Multiple Surgeries
9. CGS Administrators, LLC, LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 10/03/2024
10. First Coast Service Options, Inc., LCD L38720- Treatment of Chronic Venous Insufficiency of the Lower
Extremities; Effective 12/27/2020
11. National Government Services, Inc., LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 11/21/2019
12. Noridian Healthcare Solutions, LLC, LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
13. Noridian Healthcare Solutions, LLC, LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
14. Novitas Solutions, Inc., LCD L34924- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 10/01/2015; Revised 12/27/2020
15. Palmetto GBA LCD L39121- Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 11/16/2023
16. Wisconsin Physicians Service Insurance Corp., LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 8/31/2023
17. CGS Administrators, LLC, LCA A57305- Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of; Effective 9/26/2019; Revised 10/03/2024
18. First Coast Service Options, Inc., LCA A58250- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremity; Effective 12/27/2020; Revised 3/11/2021
19. National Government Services, Inc., LCA A52870- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 10/01/2015; Revised 01/01/2025
20. Noridian Healthcare Solutions, LLC, LCA A57706- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023
21. Noridian Healthcare Solutions, LLC, LCA A57707- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023
22. Novitas Solutions, Inc., LCA A55229- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 8/11/2016; Revised 3/11/2021
23. Palmetto GBA LCA A58876- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 01/01/2025
24. Wisconsin Physicians Service Insurance Corp., LCA A56914- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 8/29/2019; Revised 8/31/2023
25. AMA CPT Codebook
Claims Selection Criteria:
1. Provider types: Ambulatory Surgical Centers (ASC); Professional Services
2. Eligible MAC Jurisdictions: All A/B MACs
3. TOB: 083X (ASC)
4. Place of Service is limited to 24 (ASC)
5. Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
6. Include claims billed with one of the following Category 1 CPT codes:
• 36475- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated
o +36476- 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)
• 36478- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated
o +36479- 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)
• 76937- Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)
7. Exclude all claims identified with a valid Unique Tracking Number (UTN).
8. Exclude the following modifiers:
• GA- Waiver of liability statement issued as required by payer policy, individual case, covered item
• GX- Notice of Liability issued, voluntary under payer policy, non-covered item
• QO-investigational clinical service provided in a clinical research study that is in an approved clinical research study
• Q1-routine clinical service provided in a clinical research study that is in an approved clinical research study
9. Exclude any claims that will have an overpayment adjustment of less than $25.00
10. Exclude paid claims that will have an underpayment adjustment of less than $5.00
11. Error codes:
• 1600- lack of documentation
• 2100- insufficient documentation
• 2500- medically unnecessary item[s] or services
• 6000- unbundling
• HP301- Insufficient documentation to support failure of an adequate trial of conservative treatment prior to the vein ablation.
• HP302- The documentation submitted does not include history and physical findings supporting a diagnosis of symptomatic varicose veins.
• HP303- Insufficient documentation to support that the beneficiary has an absence of aneurysm in target segment.
• HP304- Insufficient documentation to support that the required vein diameter parameters for vein ablation were met per Medicare coverage criteria.
• HP305- The documentation submitted does not note the absence of thrombosis or vein tortuosity
• HP306- Insufficient documentation to support performance of test(s) to confirm the presence and location of incompetent perforating veins.
• HP308- Insufficient documentation to support other causes of edema, ulceration, and/or pain in the limbs.