TIME FOR A NEW CODE?

One of the larger frustrations over the past few years has been the increasing denial of the US guidance code (76942) when performing sclerotherapy.  A few large commercial payers, many small commercial payers and even one Medicare regional administrator will no longer pay for the guidance code stating it is either not medically necessary or experimental and investigational.  This really leaves us with two possible options.

 

Option 1, A New Code:  Rather than having two codes (36471/0 and 76942), there would be one bundled code similar to the laser or RF codes.  Doctors Stephen Daugherty, Vein Care Centers of Tennessee and Thomas Wright, Laser Lipo & Vein Center think that having a new code would be the most effective route.  They firmly believe that the current sclerotherapy codes does not take into account the skill sets and the risks involved with performing medically necessary non-visual sclerotherapy or Endovenous Chemical Ablations under Ultrasound Guidance (ECAUG).

 

The proposed ECAUG code would include the sclerotherapy elements, any small re-mapping to determine appropriate injection points, and the US guidance required for performing the sclerotherapy.  It would also include the risks and skills associated with injecting a sclerosant into somewhat deeper veins such as a perforator.  If the cost of the sclerosant (which is no longer nominal) is likewise included in the new code, this code would be of great benefit to the physician and their practice.

 

Option 2, A Need for a Study:  When we have asked the various payers why they do not cover the US guidance, their Medical Directors have noted there is no medical literature proving the need for US guidance.  We have not found any study that definitively notes why US guidance must be used in some cases.  The reason, this author is sure, is because it is so completely obvious that there is no specific study.

 

However, in order to prove the need; we need a study and paper.  We are asking that someone consider putting together the necessary documentation and literature noting when it was possible to use only visual or visual/enhanced sclerotherapy versus the need for US guidance.  We would then have something to use when pushing back against these payer policies.  If we could be consistently paid for the US guidance and the sclerotherapy codes, then we may not need a new ECAUG code.

 

My Take:  One of the con’s this author has heard is that a new code could prove to pay less than what is being paid now.  Given the lack of reimbursement by a number of payers for the US guidance and the lack of reimbursement for the sclerosant, I do not believe this to be true any longer.  If the need for guidance, along with the increased skills and risks, coupled with the cost of the sclerosant is considered, I feel certain that a bundled code would be priced by CMS at a reasonable amount.

 

Most of our readers belong to one of a number of societies.  If you agree that the time has come for a bundled ECAUG code, you should reach out to these societies and advocate for this change.

One Response to TIME FOR A NEW CODE?

  1. Bruce hoyle November 8, 2017 at 4:17 pm #

    agreed

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