Endovenous Ablation — Varicose Veins

CPT 36478
Approach Endovascular
Add-on / Variant CPTs
  • 36479 — Endovenous ablation, radiofrequency, second or subsequent vein
  • 36471 — Injection of sclerosant, single vein
Preoperative Diagnosis:

Right [left] great saphenous vein reflux with symptomatic varicose veins — CEAP class [C2–C6]

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] great saphenous vein endovenous [laser / radiofrequency] ablation with [phlebectomy / sclerotherapy]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Tech/nurse name]

Anesthesia:

Tumescent local anesthesia — [X] mL dilute lidocaine/epinephrine perivenous solution

Indications:

The patient is a [age]-year-old [male/female] with symptomatic varicose veins secondary to GSV reflux confirmed on duplex ultrasound (reflux duration [X] sec, GSV diameter [X] mm). The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The great saphenous vein was identified by ultrasound and accessed at the [knee / mid-thigh]. The [laser / RF catheter] was advanced to [2 cm below the saphenofemoral junction (SFJ)]. Tumescent anesthesia was placed perivenously under ultrasound guidance. Post-ablation duplex confirmed [no flow in the treated segment / SFJ occlusion without deep vein involvement].

Description of Procedure:

The patient was positioned supine with the leg elevated. The leg was prepped and draped. Ultrasound was used to identify the GSV at the [knee / mid-calf]. Access was obtained with a [21-gauge] micropuncture needle under ultrasound guidance. A [5 Fr] sheath was placed and the [laser / ClosureFast RF] catheter was advanced under ultrasound visualization to a position [2 cm below the SFJ].

Tumescent anesthesia ([dilute 0.1% lidocaine with 1:1,000,000 epinephrine] in normal saline) was infiltrated perivenously along the length of the GSV under ultrasound guidance, providing analgesia and compression of the vein around the catheter.

The [laser (wavelength X nm) / radiofrequency] energy was applied in a slow, controlled pullback from the SFJ to the access point per the manufacturer's protocol. Post-ablation duplex ultrasound confirmed closure of the treated GSV segment with no deep vein extension. [Stab phlebectomy of varicose tributaries was performed through [X] stab incisions.]

Compression dressings were applied. The patient was ambulated immediately.

Complications:

None

Specimens:

None

Estimated Blood Loss:

None

Drains:

None

Disposition:

The patient was ambulated immediately post-procedure. Compression stockings were applied. Follow-up duplex ultrasound at 72 hours was scheduled to confirm GSV closure and rule out DVT.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** GSV reflux, CEAP class ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** GSV endovenous ablation with ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Tumescent local — dilute lidocaine/epinephrine perivenous

INDICATIONS: .PTAGE-year-old .PTSEX with symptomatic varicose veins. Duplex: GSV reflux *** sec, *** mm. Consent obtained.

FINDINGS: GSV accessed at ***. Catheter to 2 cm below SFJ. Tumescent placed perivenously. Post-ablation duplex: GSV occluded, no deep vein extension.

PROCEDURE:
Supine, leg elevated. Prepped and draped. Ultrasound access of GSV at ***. Sheath placed. *** catheter advanced to 2 cm below SFJ under ultrasound. Tumescent anesthesia perivenous. Energy applied with pullback per protocol. Post-ablation duplex: GSV closed, no DVT. [Stab phlebectomy: *** incisions.] Compression dressing. Patient ambulated.

COMPLICATIONS: None
DISPOSITION: Ambulatory, compression applied. Duplex at 72 hours.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Ultrasound-Guided Foam Sclerotherapy

For residual or tributary varicosities, ultrasound-guided foam sclerotherapy was performed. Sodium tetradecyl sulfate [or polidocanol] foam was prepared and injected under ultrasound guidance into the target varicosities. Manual compression was applied. Compression bandaging was applied for 48 hours. Foam sclerotherapy is particularly effective for tributary varicosities and residual segments following thermal ablation.

Charting Tips
  • Document post-ablation duplex confirming GSV occlusion and absence of deep vein extension. Endothermal heat-induced thrombosis (EHIT) extending into the femoral vein is a recognized complication requiring anticoagulation. Documenting a normal post-procedure duplex protects against delayed DVT claims.
  • Document catheter tip position at 2 cm below the SFJ. Placement too close to the SFJ risks thermal injury to the femoral vein; too distal reduces efficacy. The specific measurement should be in the note.
  • Record CEAP class pre-operatively. This is required for insurance authorization and establishes medical necessity for thermal ablation over compression therapy alone.
Billing Tips
  • Radiofrequency ablation: 36475 (first vein, 5.17 wRVU) + 36476 add-on per additional vein (2.58 wRVU); laser ablation: 36478 (first vein, 5.17 wRVU) + 36479 add-on (2.58 wRVU). wRVU is identical regardless of modality.
  • Bill per incompetent vein segment treated, not per limb. GSV, SSV, and accessory saphenous veins are separately billable when each is treated with ablation.
  • Bilateral procedures: append -RT/-LT for each limb; bilateral rates apply. Document each side and each vessel treated separately in the operative note.
  • Sclerotherapy (36470 single vein, 0.73 wRVU; 36471 multiple veins, 1.46 wRVU) for residual tributaries at the same session is bundled within the ablation global. Do not bill separately. Sclerotherapy at a separate subsequent visit is separately billable.
  • Global period is 0 days (endoscopic). Post-procedure duplex surveillance, compression stocking fitting, and follow-up visits are separately billable with standard E&M codes.
  • Medical necessity documentation: payer coverage policies typically require clinical CEAP class ≥C3, failed conservative therapy (compression ×12 weeks), and duplex confirmation of reflux >0.5 seconds. Document all three before submission.
  • Duplex ultrasound for vein mapping: 93971 (unilateral extremity duplex) is separately billable at a prior visit for mapping. Intraoperative duplex guidance is bundled into ablation codes.