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Should You Add Varicose Vein Procedures?
Radiofrequency endovenous ablation is quick, easy and reasonably reimbursed.
Garth Rosenberg
Publish Date: October 10, 2007   |  Tags:   Plastic Surgery

Saphenous vein reflux is a common cause of varicose veins in the calves or inside of the leg. They're unsightly, and often painful and uncomfortable. Until recently, removing them was a tedious and not particularly well-paying procedure. Endovenous ablation, which shrinks case times and post-op bruising as well as varicose veins, could turn all that around. Here are the basics of the procedure so you can decide if treating varicose veins has a place in your case mix.

Quick and easy
Radiofrequency endovenous ablation, FDA approved in 1999, is less invasive than surgery and has a lower complication rate. You perform it percutaneously using only local anesthesia and a small catheter, resulting in quick procedures with minimal post-op discomfort.

First, you access the saphenous vein near the knee under duplex guidance. A small sheath is placed allowing passage of the catheter through the vein towards the sapheno-femoral vein junction. Tumescent anesthesia is then placed under duplex guidance around the saphenous vein sheath to allow painless passage of the heated catheter. Radiofrequency (or laser) energy delivers heat to the vein wall leading to collagen contraction and vein obliteration. Passage of the catheter through the saphenous vein takes about five minutes and is painless due to the tumescent anesthesia placed previously. After resolution of the elevated venous pressure, symptoms improve remarkably.

Pre-op, you prep and drape the patient's leg. Many physicians still sedate patients with small doses of Valium or Versed, but we prefer a local anesthetic protocol. We inject 1% lidocaine at the vein access site, numbing the insertion area of the catheter. Tumescent anesthesia - a mixture of lidocaine, sodium bicarb and saline - is mandatory.

At the completion of the procedure, no sutures are needed. The access site and surrounding area is wrapped with an ace bandage and support hose are applied. The patient may walk and drive immediately and many return to work the same day. While both laser and radiofrequency energy sources produce similar and effective results, the radiofrequency energy reduces bruising, intra-op discomfort and post-op pain.

Patients arrive at the ASC and undergo a preliminary duplex scan on the day of the procedure, either before or after the leg is prepped and draped. The initial preparation should take no more than 10 to 15 minutes. Access of the vein, placement of tumescent anesthesia, and catheter pull-back may average about 20 minutes.

Other ablation procedures
Even after saphenous vein reflux has been addressed, clusters of symptomatic or unsightly veins may remain in the thigh or calf, necessitating a follow-up micro-phlebectomy. The procedure involves removing varicose segments through a series of tiny incisions, averaging 1mm to 2mm in length. Like endovenous ablation, this procedure may be done under simple local anesthesia . The number of incisions needed is dependent on the distribution and number of veins to be treated.

Rosy Reimbursement Outlook for Endovenous Ablation

Endovenous ablation is a largely reimbursable procedure if patients meet certain pre-operative guidelines. Typically, common symptoms must be present: pain, aching, burning, throbbing or skin discoloration. Patients must also present with ultrasound-proven saphenous vein reflux and documentation that they've worn support hose for an average of three months. Some carriers require only six weeks of support hose treatments, others as much as six months; there isn't a global standard. Check with your contracted payers to determine specific pre-approval requirements.

Once patients gain approval for varicose vein treatment, you want to ensure your facility receives full reimbursement. Medicare recently created two sets of CPT codes for vein ablation. The first set (CPT 36475 and 36476) is used for radiofrequency ablation; the second set (CPT 36478 and 36479) applies to laser techniques. The first number in each set reports the initial vein treated; the second code pertains to additional veins treated in the same leg through separate access sites. The codes include reimbursement for the image-guided and monitoring components of the procedures.

An important note: Both sets of codes are weighted differently, depending on the type of facility that hosts the procedure. CPT 36475 has a relative value unit of 9.62 in the hospital setting, but a value of 58.48 when the procedure is performed in the office, according to the Society for Vascular Surgery. The reason for the difference: Medicare has a separate fee schedule for each locale. The reimbursement for procedures performed in office suites cover expenses ordinarily covered in facility fees - line items such as supplies, labor and equipment. Physicians operating in an office suite receive one payment, typically around $2,000, and must determine if that payment is a cost-effective option for performing endovenous ablation.

Office-based surgeons can't claim a facility fee in addition to this all-inclusive professional fee - even if the office suite has accredited ASC status. That's considered double-dipping. Procedures performed in the ASC, meanwhile, do qualify for a facility fee that has increased significantly thanks to changes imposed to Medicare's ASC payment list. In January, CPT codes 36475 through 36479 moved from Group 3 to Group 9 in the payment schedule. The codes are now reimbursed at $1,339, a 163 percent increase over the 2006 payment rates.

A pair of CPT codes also applies to phlebectomy procedures. The first, CPT 37765, should be used for phlebectomy involving 10 incisions to 20 incisions. The second, CPT 37766, applies to procedures calling for more than 20 incisions. If fewer than 10 stabs are used, note 37799 in the op report. Generally, Medicare allows ASC facility fees of roughly $530 per phlebectomy. Most other payers reimburse significantly higher than that, sometimes as much as 150 percent to 200 percent of the Medicare rate.

- Garth D. Rosenberg, MD, FACS

Endovenous Ablation and Phlebectomy: Stagger or Same Day?

There are two schools of thought with respect to performing endovenous ablation and phlebectomy on the same day. Economic and clinical considerations may necessitate that you stagger the procedures, offering support to the conservative approach.

On the facility fee side, Medicare's multiple procedure payment reduction rules mandate the reimbursement of 100 percent of the primary procedure and 50 percent of subsequent procedures. So, performing phlebectomy during the same operative session as vein ablation will halve your phlebectomy fee.

The clinical reasons for splitting the procedures are more compelling. Endovenous ablation of the saphenous vein relieves pressure on secondary veins, ultimately reducing the source of increased pressure. After endoablation procedures, varicose veins in other areas of the leg may return to normal over several weeks. By waiting, the need for the phlebectomy procedure may be eliminated.

- Garth D. Rosenberg, MD, FACS

Sclerotherapy is very effective for spider veins and some smaller varicose veins. By instilling various medications into these small veins, we cause sclerosis of the vessels and eventual obliteration. Slowly, the veins are resorbed and an excellent cosmetic result is achieved. It is vital to treat any proximal vein insufficiency before administering sclerotherapy to lower leg veins. Failure to do so can lead to poor resolution of the injected veins as well as hyperpigmentation from hemosiderin deposition. Proximal reflux is well treated by endovenous ablation (when saphenous reflux is found) and microphlebectomy.

Several different sclerotherapy solutions are available. Hypertonic saline (23.4%) was commonly used until newer detergents became recognized as giving better results with fewer side effects. Sotradecol (sodium tetradecyl sulfate injection) and Polidocanol (aethoxysklerol) are the two most widely used agents. You can use these compounds as a foaming agent for more effective treatments.

Sclerotherapy is done in an office setting, so no ASC designation is needed. No facility fee is attached to either sclerotherapy or duplex-guided sclerotherapy. As this is generally a cosmetic procedure, most payers don't cover this form of therapy unless specific payer guidelines are met.

Your startup costs
Prepping your facility to host endovenous ablation requires certain overhead investments. The procedure is performed under ultrasound guidance, which lets the physician navigate the catheter safely and effectively in the vein. Depending on the make and model, the ultrasound machine will cost between $50,000 and $100,000. You may also need to contract with an ultrasound tech, depending on your physician's comfort level and skill. Years of experience let me handle the ultrasound navigation responsibilities with one hand while guiding the catheter with the other. Your physician may not have the same ability, especially if you're adding the procedure to a multi-specialty center. You'll also need to purchase a laser frequency or radiofrequency generator to allow delivery of the energy required to close the vein.

The required single-use catheter is by far the most expensive supply. Costs are variable depending on the laser fiber used or radiofrequency pricing. Other disposable supplies include the catheter sheath, drapes, syringes, needles and ultrasound probe. Total disposable supply costs may be between $500 and $800 per case.

Where you perform your cases will determine your level of reimbursement (see "Rosy Reimbursement Outlook for Endovenous Ablation" on page 40). Physicians operating in an office suite receive an all-inclusive professional fee of around $2,000 and can't claim a facility fee - even if the office suite has accredited ASC status. Procedures performed in the ASC qualify for a Group 9 facility fee ($1,339).

Dictated by demand
Until several years ago, we had a very active arterial practice while managing a significant volume of patients with venous disease. We adopted the radiofrequency method of vein ablation in 2001 when we realized how positively it would impact our patients. This heightened awareness of venous disease has enabled us to devote our attention and practice development efforts exclusively to the management of venous disorders.

Now that this highly effective technique is available, more patients will be evaluated and treated with excellent results. Managers and physicians in other office settings must determine if the single reimbursement payment is cost beneficial, while those operating in surgery centers must balance costs against the efficiency of fitting the procedure into a diverse case mix.