Sclerotherapy Injections

One Lump or Two?
by Cheryl Nash and AJ Riviezzo
Many practices are in the habit of automatically using the CPT code 36471 – sclerotherapy injection. We would caution selecting the correct code based on the number of veins injected. Code 36471 is used for injection into two or more veins. If only one vein is being injected, regardless of the number of injections, you should use CPT code 36470 – sclerotherapy injection, single vein. Reimbursement is, of course, a bit less than the 36471, sclerotherapy injection, multiple veins (by about $30).

You can still perform bilateral injections even if one injection is into multiple veins and one is into only one vein. Coding would be 36471 (RT or LT) and 36470 (RT or LT). Do not forget to bill for your diagnostic ultrasound prior to the procedure when you re-map the leg (93970 or 93971) and for the utrasound needle guidance if performed (76942 RT or LT).

Finally, Medicare and the commercial payers treat this as a surgical procedure. There should be a procedure report for your non-cosmetic sclerotherapy injections stating where, how, and why the injection was performed.