Retrospective evaluation of the need of a redo surgery at the groin for the surgical treatment of varicose vein

Abstract

This article compares surgical approaches to patients with varicose veins for postoperative complications as well as hemodynamic and clinical results. CPT code 37720 originally described “ligation and division and complete stripping, long or short saphenous vein” and CPT code 37730 defined “ligation and division and complete stripping, long and short saphenous veins.” In 2004, an increasing number of insurance denials became evident when the greater saphenous vein (GSV) was removed from the groin to just below the knee, leaving a distal remnant. The carrier's rationale was based on the code description using the word “complete” and the surgeon ignoring the calf/ankle section of GSV. Given the proven efficacy of treatment with GSV removal to the knee, CPT codes 37720 and 37730 were retired in 2006 and replaced with CPT code 37722 (ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below) and CPT code 37718 (ligation, division, and stripping, short saphenous vein). In the 2010 Medicare Physician Fee Schedule (MPFS), they were valued at 13.60 total relative value units (RVUs) and 12.18 total RVUs, respectively. Ligation at the saphenofemoral junction without stripping of the long saphenous vein is described by CPT code 37700 and, at the saphenopopliteal junction without stripping of the short saphenous vein, by CPT code 37780. In the 2010 Medicare Physician Fee Schedule (MPFS), they were valued at 7.04 total RVUs and 7.26 total RVUs, respectively. Stab phlebectomy coding was introduced in 2004. The original CPT application divided the code structure into three distinct categories: 1-15, 16-30, and 31+ incisions. However, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) felt this coding schema imparted too high of a risk for abuse and referred it back to the CPT Editorial Panel. In response they created, CPT code 37765 (stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions) and 37766 (stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions). Those procedures that involve less than 10 stab incisions are required to submit the unlisted vascular code (CPT code 37799). Medical records are usually required and payment is subject to a medical director's review of the claim. At present, the CPT codes 37765 and 37766 are valued only in the “facility” setting at 12.87 total RVUs and 15.79 total RVUs, respectively in the 2010 MPFS. Reimbursement is based on the site of service. When a procedure is done in a hospital (i.e., a facility), the hospital will bill separately for its expense. When a procedure is done in a physician's office (i.e., a non-facility), there is additional cost to the medical practice for nursing, rent, sterile supplies, etc. The work RVUs and malpractice RVUs are the same but the practice expense is higher in the non-facility. Seventy-two percent of 2008 Medicare claims according to the RUC database for these codes were done in the office. In response, the Society for Vascular Surgery recruited the Society for Interventional Radiology and the American Academy of Dermatology for input and successfully valued the additional practice expense in the “non-facility” at the February 2010 RUC. The final reimbursements will be published by the Center for Medicare and Medicaid Services in their 2011 final MPFS. Private carriers will obviously value these surgeries using their own methodology. CPT code 37761 (ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg) was created in response to a RUC site of service concern over the CPT code 37760 (the Linton procedure). CPT code 37760 is a more extensive intervention with RVU content that includes 2.5 inpatient days in the post-op 90 day global period but only 6% were inpatient status in the 2008 Medicare claims data (55% were done in a physician office and 39% in a facility as an outpatient). The final value for 2010 in the MPFS of the new code was 15.91 total RVUs compared to 17.74 for the full Linton procedure. Lastly, CPT code 37785 (ligation, division, and/or excision of varicose vein cluster(s), 1 leg) describes a fairly limited surgical treatment of varicose veins. It has a National Correct Coding Initiative (NCCI) edit with most other venous surgical descriptions. It is currently the one venous surgical code with a site of service differential in the 2010 MPFS: 7.28 total RVUs in the facility and 9.67 total RVUs in the non-facility.