The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 36475 - Endovenous ablation therapy of incompetent vein. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows

Top Denial Reasons:

• Documentation does not support the modifiers billed.
• Documentation does not support medical necessity.
• Documentation submitted for incorrect date of service

Educational Resources

• How to Respond to ADR
• Required Documentation
• Signature Requirement Questions and Answers
• JE LCD L34209

Education

JE LCD

Local Coverage Determination L34209 "Treatment of Varicose Veins of the Lower Extremities" discusses the coverage requirements for these services. This LCD can be located at the following web address: https://med.noridianmedicare.com/web/jeb/policies/lcd/active. LCD L34209 provides coverage guidance for vein ablation of varicose veins of the lower extremities. When conservative measures are unsuccessful, and symptoms persist, the next step has been compressive sclerotherapy or vein ablation.

Compressive sclerotherapy is indicated for local small to medium symptomatic varices, isolated incompetent perforators, or recurrence of symptomatic varices after adequate surgical removal of varices. Compressive sclerotherapy is not an appropriate option for large, extensive or truncal varicosities. A three-month trial of conservative therapy i.e. exercise, periodic leg elevation, weight loss, compressive therapy, avoidance of prolonged immobility where appropriate is required.

Medical Necessity

As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.

Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. In order to be considered medically necessary, items and services must be proven as safe and effective.

Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary in order for a claim to be properly evaluated. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.

Modifiers

The documentation needs to support the modifiers billed. An example of this is when modifier 50 is used to report bilateral procedures that are performed at the same operative session as a single line item. Do not use modifiers RT and LT when modifier 50 applies. Modifier 50 applies to any bilateral procedure performed on both sides at the same operative session. The bilateral modifier 50 is restricted to operative sessions only. Refer to CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6, CPT® and HCPCS manual.

Incorrect Date of Service

The date of service must be included on each page of the documentation and must correlate to the date of service billed. A claim will be denied, for example, when the date of service billed and the date of the service on the documentation are not the same.  Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, 3.6.2.2. and MLN Matters, Guidance on Coding and Billing Date of Service on Professional Claims, number: SE17023.