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Official Description

Injection of sclerosant; single incompetent vein (other than telangiectasia)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 36470 involves the injection of a sclerosant into a single incompetent vein, which is a vein that is unable to properly transport blood due to valve failure. This procedure is specifically indicated for veins that are not classified as telangiectasia, which are small, superficial blood vessels. The sclerosant is a chemical agent that, when injected, causes irritation and inflammation of the vein walls. This reaction leads to the veins sticking together and eventually closing off permanently. As a result, the treated varicose veins may gradually disappear or become less visible as the body naturally reabsorbs the affected tissue. The procedure is typically performed in an outpatient setting and may involve the documentation of the varicose veins through photography to assess the extent of the condition prior to treatment. Proper skin preparation, including cleansing with an antiseptic, is essential to minimize the risk of infection during the injection process. The physician employs a technique that involves stretching the skin taut to facilitate the injection of the sclerosant along the length of the vein, often requiring multiple injections for effective treatment of the vein.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The injection of a sclerosant into a single incompetent vein is indicated for the treatment of varicose veins that exhibit incompetence due to valve failure. The following conditions may warrant this procedure:

  • Varicose Veins Varicose veins are enlarged, swollen veins that often appear blue or dark purple and can cause discomfort, pain, or cosmetic concerns.
  • Incompetent Veins These veins are characterized by improper functioning of the valves, leading to blood pooling and increased pressure within the vein.
  • Symptoms of Venous Insufficiency Patients may experience symptoms such as aching, heaviness, or swelling in the legs, which can be alleviated through this procedure.

2. Procedure

The procedure for the injection of a sclerosant into a single incompetent vein involves several key steps to ensure effective treatment:

  • Step 1: Patient Preparation The patient is positioned comfortably, and the area around the varicose vein is prepared. This includes cleansing the skin with an antiseptic solution to reduce the risk of infection.
  • Step 2: Documentation Prior to the injection, the physician may photograph the varicose veins to document their appearance and extent. This serves as a reference for evaluating the effectiveness of the treatment.
  • Step 3: Skin Tautening The physician stretches the skin over the varicose vein taut using one hand. This technique helps to stabilize the vein and facilitate the injection process.
  • Step 4: Injection of Sclerosant With the skin taut, the physician injects the sclerosant into the vein using a syringe. The sclerosant is administered along the length of the vein, and multiple injections may be necessary to ensure complete treatment of the affected area.
  • Step 5: Post-Injection Care After the sclerosant is injected, the physician may apply compression to the treated area to promote closure of the vein and minimize swelling. The patient is typically monitored for a short period before being discharged.

3. Post-Procedure

Following the injection of the sclerosant, patients may experience some discomfort or swelling in the treated area, which is generally mild and temporary. It is important for patients to follow any post-procedure instructions provided by the physician, which may include wearing compression stockings to support the healing process and reduce the risk of complications. Patients are usually advised to avoid strenuous activities for a short period and to monitor the injection site for any signs of adverse reactions. Over time, as the body reabsorbs the treated vein, the varicose veins should become less noticeable, and venous blood flow will be redirected to healthier, deeper veins.

Short Descr NJX SCLRSNT 1 INCMPTNT VEIN
Medium Descr INJECTION SCLEROSANT SINGLE INCMPTNT VEIN
Long Descr Injection of sclerosant; single incompetent vein (other than telangiectasia)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 1
CCS Clinical Classification 61 - Other OR procedures on vessels other than head and neck
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GA Waiver of liability statement issued as required by payer policy, individual case
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2018-01-01 Changed Long medium and short descriptions changed.
Pre-1990 Added Code added.
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