CPT Code 36471: Under Sclerotherapy of Telangiectasia and Incompetent Veins

What is CPT code 36471?

CPT code 36471, as defined by the American Medical Association, describes sclerotherapy procedures that involve the injection of a sclerosing solution into multiple incompetent veins within the same leg during a single session. Unlike treatments for spider veins (telangiectasia), this procedure targets larger symptomatic varicose veins or other vascular malformations. Providers, such as vascular surgeons, phlebologists, or dermatologists, typically dispense medical services using sclerosing agents like sodium tetradecyl sulfate or polidocanol. These agents irritate the vein wall, leading to closure, fibrosis, and eventual reabsorption. CPT 36471 is reported regardless of the number of veins treated in the same leg during a single procedure, and proper documentation supports establishing medical necessity for this treatment.

What is sclerotherapy for multiple veins on one leg?

Sclerotherapy for multiple veins on one leg involves injecting a chemical solution into several varicose veins simultaneously to cause their collapse and absorption by the body. It is typically performed when multiple incompetent veins cause symptoms like pain, swelling, discomfort, or visible cosmetic concerns. This minimally invasive procedure effectively treats chronic venous insufficiency and significantly improves symptoms associated with multiple varicose veins.

CPT code 36471 documentation requirements

Accurate documentation is essential for compliance with local coverage determinations and guidelines set by Medicaid services and other payers.

Indication for sclerotherapy

Clearly document the clinical indication for sclerotherapy procedures, such as symptomatic varicose veins, venous insufficiency, or associated complications. Explicit documentation supports medical necessity.

Laterality and leg treated

Specify clearly the leg treated (right or left) since CPT 36471 is reported per leg. Properly documenting laterality is essential for accurate coding, particularly if a bilateral procedure is performed.

Number of veins treated

Documentation must clearly indicate treatment of multiple incompetent veins in the same leg. This differentiates CPT 36471 from other sclerotherapy codes for single-vein treatments.

Type and concentration of sclerosing agent

Record the exact sclerosing agent used, along with its concentration, to justify the appropriateness of treatment and support clinical outcomes.

Volume injected and injection technique

Clearly document the volume of the sclerosing solution injected into each vein and the injection technique utilized. Accurate recording ensures appropriate clinical tracking and billing justification.

Patient tolerance and post-procedure instructions

Detail patient response to the procedure, including tolerance, immediate outcomes, and any side effects or complications. Provide clear post-procedure care instructions in the medical record.

Ultrasound guidance documentation

Include ultrasound guidance only if medically necessary, properly documented, and specifically used for targeting incompetent veins. Documenting ultrasound use can support separate billing when permitted.

CPT code 36471 billing guidelines

Proper billing ensures adherence to the National Correct Coding Initiative (NCCI) and accurate reimbursement, based on established relative value units and conversion factors.

Report once per leg per session

CPT 36471 is billed once per leg treated, regardless of the number of veins injected in that same leg during the session. Clearly document laterality to support accurate billing.

Differentiate from CPT 36470

Use CPT 36470 when treating only a single vein. CPT 36471 is specifically for multiple veins in one leg, which must be clearly documented.

Reporting bilateral procedures

If both legs undergo sclerotherapy procedures during the same session, use modifier -50 (bilateral procedure) or modifiers -LT/-RT appropriately. Verify payer fee schedules and guidelines for correct bilateral billing practices.

Supplies and anesthesia included

All necessary supplies and local anesthesia required to perform sclerotherapy are bundled into CPT 36471 and cannot be billed separately.

Cosmetic vs. medical necessity

Review and comply with payer-specific local coverage determinations to establish medical necessity. Clearly differentiate cosmetic treatments (e.g., spider veins) from medically necessary treatments for symptomatic varicose veins.

Other relevant CPT codes

• 36470 – Sclerotherapy, single vein
• 36465–36466 – Injection of sclerosing solution with ultrasound guidance (truncal veins)
• 76942 – Ultrasound guidance for needle placement (if separately billable)
• 93970–93971 – Duplex ultrasound scanning, venous studies of extremities