2025 CPT code 36475
(Active) Effective Date: N/A Revision Date: N/A Surgery - Vascular Procedures Surgery Feed
Endovenous ablation therapy of an incompetent vein in an extremity using radiofrequency, including imaging guidance and monitoring; first vein treated.
Modifiers may be applicable depending on the specific circumstances of the procedure.Consult the most recent CPT codebook for information on modifiers and their appropriate use.
Medical necessity is established by the presence of symptomatic varicose veins resulting from venous insufficiency, as documented clinically and through appropriate imaging studies (e.g., ultrasound).The procedure should be considered medically necessary to alleviate symptoms such as pain, swelling, and cosmetic concerns, and to prevent complications such as venous ulcers.
The physician is responsible for all aspects of the procedure, from patient preparation and anesthesia to the insertion of the catheter, ablation of the vein, and post-procedure care. This includes appropriate imaging guidance and monitoring of the patient throughout the procedure.
In simple words: This code describes a procedure to close off a diseased vein in your leg or arm. A thin tube is inserted into the vein, and radiofrequency energy heats and seals the vein shut, preventing blood from flowing backwards. Ultrasound is used to guide the procedure, and the entire process, from inserting the tube to sealing the vein, is included in this one code. If more than one vein needs treatment, additional codes will be used.
This CPT code 36475 encompasses endovenous ablation therapy of a single incompetent vein located in an extremity.The procedure involves percutaneous access, radiofrequency energy delivery to ablate the vein wall, and includes all necessary imaging guidance (e.g., ultrasound) and monitoring during the procedure. This code is inclusive of the introduction of the catheter, radiofrequency probe, and all steps required to perform the ablation and achieve hemostasis.Additional veins treated require the use of add-on code +36476.
Example 1: A 55-year-old female presents with symptoms of varicose veins in her left leg.An ultrasound confirms incompetence of the great saphenous vein. The physician performs radiofrequency ablation of the great saphenous vein using code 36475., A 62-year-old male presents with varicose veins and leg pain. Ultrasound reveals incompetence of the small saphenous vein and a smaller tributary vein.The physician performs ablation of the small saphenous vein using 36475, and an additional tributary vein ablation using +36476., A 48-year-old female with chronic venous insufficiency has a large varicose vein in her right thigh.The physician performs endovenous ablation using 36475, and also performs sclerotherapy on the same vein using code 36470. Both codes can be reported in this case.
Complete medical history and physical examination documenting the presence of varicose veins and associated symptoms.Pre-procedure ultrasound images clearly showing the location and extent of the incompetent vein(s).Operative report detailing the procedure performed, including type of ablation, catheter used, energy settings, and any complications.Post-procedure ultrasound images documenting vein closure.Patient consent forms.
** Ultrasound guidance is integral to this procedure and is included in the code. Do not report ultrasound guidance separately.The code is only for the first vein treated; additional veins require separate reporting using add-on code +36476.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: This information is not available in the provided source.Consult the most recent CPT codebook or a medical billing resource for the current RVUs.
- Global Days: This information is not available in the provided source.Consult the most recent CPT codebook or a medical billing resource for details on global surgical periods.
- Payment Status: Active
- Modifier TC rule: The information is not provided in the source. Consult the most recent CPT codebook or a medical billing resource for details.
- Fee Schedule: This information is not available in the provided source.Consult fee schedules from relevant payers or medical billing resources.
- Specialties:Vascular Surgery, Phlebology
- Place of Service:Office, Ambulatory Surgical Center