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2025 CPT code 36465

Injection of non-compounded foam sclerosant into a single incompetent extremity truncal vein using ultrasound guidance.

Follow all CPT coding guidelines for surgical procedures.Accurate documentation is critical for proper code selection and reimbursement.

Modifiers may be applicable depending on the circumstances of the service. Refer to the CPT manual for specific modifier guidelines.

Medical necessity is established by the presence of symptomatic venous insufficiency or varicose veins refractory to conservative management. Documentation should demonstrate the clinical rationale for the procedure and its appropriateness for the patient's condition.

The physician is responsible for patient preparation, ultrasound-guided identification of the diseased vein, injection of the foam sclerosant, application of pressure to the injection site to prevent bleeding, and post-procedure care.

IMPORTANT:For multiple incompetent truncal veins in the same leg, use CPT code 36466.For other incompetent veins (excluding telangiectasia), use CPT codes 36470 (single vein) and 36471 (multiple veins, same leg).For other techniques like mechanochemical, radiofrequency, or laser endovenous ablation, or endovenous ablation with chemical adhesive, refer to the appropriate CPT codes (36473-36479, 36482-36483).

In simple words: This code describes a procedure where a doctor injects a special foam solution into a single large, damaged vein in a leg or arm to close it.Ultrasound is used to guide the injection.

This CPT code encompasses the injection of a non-compounded foam sclerosant solution into a single incompetent truncal vein in an extremity.Ultrasound guidance is used to direct the dispersion of the foam sclerosant. The procedure includes all necessary imaging guidance and monitoring. Examples of truncal veins include the great saphenous vein and accessory saphenous vein.

Example 1: A 55-year-old female presents with a large varicose vein in her right leg.The physician performs ultrasound-guided injection of non-compounded foam sclerosant into the great saphenous vein., A 62-year-old male presents with an incompetent accessory saphenous vein in his left leg.The physician uses ultrasound to guide the injection of non-compounded foam sclerosant., A 48-year-old female with chronic venous insufficiency has a single large incompetent truncal vein in her left leg. The physician uses ultrasound guidance to inject non-compounded foam sclerosant into the affected vein.

Complete medical history including symptoms, physical examination findings, relevant diagnostic imaging (e.g., ultrasound), detailed description of the procedure including the vein treated, amount and type of sclerosant used, and post-procedure assessment.Consent form should be documented.

** This code is specific to the injection of non-compounded foam sclerosant.The use of compounded foam sclerosant or other sclerosing agents would require different codes.Always refer to the most current CPT coding manual for the most up-to-date information.

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