Question & Answer on CPT code 37765 documentation requirements & preauthorization

by  Michelle Herbert, CPC
July 31st, 2014

Question:

is there a sample note to code 37765, our surgeon does

Answer:

Most third party payers are requiring a pre authorization on these vein codes.

Provider documentation must include the failed conservative treatment.

The following is the documentation and authorization requirements

1. A 3‐month trial of conservative therapy such as exercise, periodic leg elevation, weight loss,

compressive therapy, and avoidance of prolonged immobility where appropriate, has failed, AND

2. The patient is symptomatic with varicose veins of at least 3 mm and has one or more of the

following:  

• Pain, aching cramping burning itching and or swelling during activity or after prolonged

standing severe enough to impair mobility.

• Recurrent episodes of superficial phlebitis.

• Non‐healing skin ulceration.

• Bleeding from a varicosity.

• Stasis dermatitis.

• Refractory dependent edema.

3. The treatment of spider veins/telangiectasis (36468) will be considered medically necessary only

if there is associated hemorrhage (ICD‐9 459.0).

4. If sclerotherapy is used with endovenous ablation, it may be covered if the criteria for reasonable

and necessary as described in this guideline are met.  This applies to varicose veins in the same

leg as the endovenous ablation done on the day of the ablation or within the first 6 months after

the ablation.  Any need for sclerotherapy to treat residual varicose veins after this period would

then need to have an additional 3 months of conservative treatment and meet the other criteria

as outlined above.

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

The patient's medical record must document the following:

• history and physical findings supporting a diagnosis of symptomatic varicose veins;
• failure of an adequate trial of conservative treatment as described in the "Indications" section of this LCD;
• exclusion of other causes of edema, ulceration and pain in the limbs;
• performance of appropriate tests to confirm the presence and location of incompetent perforating veins;
• location and number of varicosities, level of incompetence of the vein and the veins involved; and
• necessity of utilizing ultrasound guidance, if used.

The medical record must also include pre-treatment photographs of the varicose veins for which claims for sclerotherapy are submitted to Medicare. These photographs must be made available to the carrier upon request for review