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Venous Ablation in Same Leg 36475 & 36476 Clarification

Oscar Posted Mon 12th of December, 2016 04:54:49 AM
Please answer the following coding question. 1) My doctor has ablated one incompetent vein in Left leg two weeks/months ago and we have reported 36475 as first vein ablated and on that day he didn't perform any other vein ablations in the same leg. After two months, again my doctor has ablated second vein in the same leg, in this case we have reported 36476 as an Add-on code. Ablation technician also suggested same that in the same leg what ever the days gap we have to report 36476 for second & subsequent veins ablation. is it correct or not? My doubt is since it is not on the same day can we report 36475 again even it is in same leg and second vein? please clarify.
SuperCoder Answered Tue 13th of December, 2016 02:41:09 AM

Hi Oscar,

Here is the explination to the above question:

  • In the same session:

When the second and subsequent veins are treated in a single extremity (each through separate access sites), the treatment of the second, third, fourth, etc, vein(s) is represented in one CPT code (36476 or 36479). When a provider treats multiple veins in the same extremity during the same session, the add-on code is reported once, irrespective of the number of veins treated. No additional reporting occurs after the second vein is treated.

For example, if four veins are treated in the same extremity using radiofrequency, code 36475,Endovenous ablation therapy of incompetent vein, extremity, inclusive
of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated,should be reported with the treatment of the remaining three veins reported using code 36476,Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) only once.

  • In different session:

35475 is code for radiofrequency ablation of first vein and 36476 is used when we treat a second vein like SSV or accessory saphenous vein at the same setting. The reason the 36476 has less dollar amount is because we can use the same catheter to treat the second vein at the same setting. Now when the second vein is treated on a different day it goes back to 36475 since its all new equipment.  I hope this helps.

SuperCoder Answered Wed 14th of December, 2016 07:32:30 AM

Here is the answer for your follow up question:

Q: If 36475 is used on 1 leg, however, after a gap of 2 months or whatever is the gap, the same procedure is repeated, should we still use 36475 or 36476 for the same leg on a second or subsequent vein.

Ans: After a gap of 2 months we will still use 36475 (global period 0). Moreover, CPT 36476 is an "add on" Code and must never be reported as a stand-alone code (cannot be billed without the primary code). Thank you.

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