2025 CPT code 36471
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Cardiovascular System - Venous Procedures Surgery Feed
Injection of sclerosing solution into multiple incompetent veins (excluding telangiectasia) in the same leg.
Modifiers may be used to indicate multiple procedures (51), bilateral procedures (50), or other relevant circumstances as per CPT guidelines.
Medical necessity for sclerotherapy is established when a patient has symptomatic varicose veins or other incompetent veins causing pain, swelling, or cosmetic concerns.The procedure may also be medically necessary to prevent complications, such as ulceration or bleeding. The specific criteria for medical necessity may vary by payer.
The physician is responsible for pre-procedural evaluation of the patient, including assessment of medical history and contraindications. They perform the injection of the sclerosant, monitor the patient during and immediately after the procedure, and provide post-procedural care instructions.They are also responsible for documentation of the procedure and its outcome.
In simple words: This code describes a procedure where a doctor injects a special solution into multiple varicose veins in one leg to make them shrink and disappear. The solution is injected directly into the veins, which causes the vein walls to close up.The doctor then applies pressure to stop any bleeding.
This CPT code reports the injection of a sclerosing solution into more than one incompetent vein within the same leg.This procedure is commonly used to treat varicose veins and other vascular malformations, excluding telangiectasia (spider veins). The procedure involves inserting a syringe containing the sclerosing solution directly into the affected veins, causing the vein walls to collapse and the veins to be reabsorbed by the body.Pre- and post-injection care is included.Ultrasound guidance may be used and should be coded separately.This code does not include the cost of the sclerosing solution itself.
Example 1: A patient presents with multiple varicose veins in their left leg. The physician performs sclerotherapy, injecting a sclerosant into multiple veins in the left leg. Code 36471 is reported., A patient with several reticular veins in their right leg undergoes sclerotherapy.The physician injects a sclerosant solution into multiple veins. Code 36471 is reported., A patient has venous insufficiency with multiple varicose veins in one leg. The procedure is performed with ultrasound guidance.Code 36471 is reported along with code 76942 (ultrasound guidance).
* Comprehensive medical history, including any allergies or contraindications to the sclerosing agent.* Detailed description of the veins treated, including location, size, and number.* Type and amount of sclerosing solution used.* Documentation of the procedure itself, including injection technique and any complications.* Post-procedure assessment and instructions provided to the patient.* Any imaging studies performed (e.g., ultrasound), including relevant images.
** The sclerosing agent used is included in the procedure code and should not be billed separately.The number of veins treated should be clearly documented.
- Revenue Code: P6C (Medicare Fee Schedule: MINOR PROCEDURES - OTHER)
- RVU: The relative value units (RVUs) for CPT code 36471 vary based on factors such as geographic location and facility type.Medicare national average payment amounts are available through publicly accessible resources.Consult the specific payer's fee schedule for the most accurate and up-to-date reimbursement information.
- Payment Status: Active
- Fee Schedule: Fee schedules vary by payer and location.Historical fee schedule information can be accessed through publicly available resources such as the CMS website for Medicare data, or through individual payer websites.
- Specialties:* Phlebology* Vascular Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center