Ask Dr. Z

"46-year-old male with history of RLE venous insufficiency with swelling, VV, and associated inflammatory change presenting for further superficial venous ablation. Limited US of the RLE was performed. Patient was then prepped and draped in usual sterile fashion utilizing chlorhexidene solution. A timeout was then performed identifying the correct patient, site, and procedure. 2% lidocaine was infiltrated for local anesthesia. A 25 gauge butterfly needle was then advanced into a superficial venous branch along the medial aspect of the lower calf. 6 mL of Varithena was then instilled with pressure held above/below the targeted venous segment for ~10 minutes.

Findings: 1) Limited US shows residual infragenicular GSV as well as two enlarged/incompetent venous tributaries extending along the anterior shin/medial aspect of the ankle (image stored). 2) Intraprocedural US images show sclerosant within all targeted venous structures (image stored)."

Physician confirmed that one truncal and two tributary veins txed. Is this all just a 36465-RT, or can the 36471-RT also be coded?