Ask Dr. Z

Our coders are having trouble differentiating between coding 36468 vs. 36471 with the documentation that follows. We believe the report represents a 36468 procedure, but due to the "varicose" vein verbiage the physician feels this report should be coded as 36471. What is the correct way to code the report below? The physician's typical 36471 reports normally reference traditional sclerotherapy for refluxing varicose veins treated, so the surface vs. traditional sclerotherapy is confusing.

"Patient presents today for medically necessary RLE surface sclerotherapy. Signed consent was obtained. The patient was placed on the table in supine position, and legs were cleaned with alcohol and 4 x 4 gauze. Utilizing a vein light, the varicose, reticular, and spider veins were injected with polidocanol 0.5% utilizing 1 ml syringes and 30 gauge 1/2" needles for a total of 3 mls. The treatment was diffuse involving the lateral, posterior, and medial aspects of the right leg. The patient tolerated the procedure well and was instructed to wear compression hose for ten days."