On March 25 through 30, 2004, in Phoenix, the Society of Interventional Radiology held its 29th annual scientific meeting. A series of presentations explored the role of interventional radiologists in treating venous insufficiency using minimally invasive methods. A recent survey 1 from the Department of Radiology, Yale University School of Medicine, New Haven, Conn, found that 86% of interventional radiologists who responded to the telephone survey were not using endovascular techniques of any kind to treat varicose veins. Of these, however, 60% wanted to do so, and 41% expected to do so within 5 years.
THE ENDOLUMINAL SOLUTION
Robert J. Min, MD, MBA, Cornell Vascular, Weill Medical College of Cornell University, New York, presented The Big Picture. He listed the disadvantages of ligation and stripping, which has been the traditional treatment for varicose veins: the procedure is performed on an inpatient basis under general anesthesia, incurring high costs; there is prolonged convalescence; and complications of the surgery can include blood loss, scarring, infection, and paresthesias. Recurrence of varicosities is not uncommon.
The less-invasive techniques developed to address these problems are ultrasound-guided sclerotherapy, radio-frequency (RF) catheter ablation, and endovenous laser treatment. The last of these three has been highly successful; in one series 2 of 1,000 patients, for example, more than 99% experienced symptom resolution, fewer than 7% showed evidence of recurrence within 2 years, and there were no skin burns, paresthesias, or deep-vein thromboses. Overall, laser therapy is associated with lower risks, more rapid recovery, better results, reduced complication rates, and lower costs, as compared with conventional ligation and stripping, Min reported.
Because of these advantages, the potential market for treatment is quite large. According to Min, as many as half of people more than 50 years old may exhibit venous insufficiency, and up to 8% of US residents experience symptoms as a result. Of these, many are unwilling (or unable) to undergo traditional treatment, but may well be candidates for laser therapy.
Once the infrastructure needed to treat varicose veins is in place, several other conditions can be addressed, constituting what Min described as an opportunity for leverage: procedures can be performed to treat liver tumors, uterine fibroids, spider veins, peripheral arterial disease, and vertebral fractures. The resulting financial impact on an interventional practice can be profound; in one example presented by Min, total revenues were nearly doubled.
The practice must, of course, invest time and money in the laser service. Complete patient care must be provided, with appropriate staffing and space allotted for reception and scheduling, a waiting area, a consulting area, and a treatment room.
Tools of the Trade was presented by Melvin Rosenblatt, MD, clinical associate professor, New York University and Yale University, and medical director of Connecticut Image Guided Surgery, Milford, Conn. He stated that the tools of invasive techniques used to treat venous insufficiency have become relics and will be entirely abandoned in the near future; vein strippers, he noted, have no place in a modern practice.
Endovenous ablation tools prevent retrograde flow by producing complete occlusion of the problem vein. The occlusive device is placed into the vein through a small incision and then pushed forward to the most distant problem area. As it is withdrawn, it closes the vein behind it using RF or laser energy.
Ultrasound-guided sclerotherapy is similar in concept because it uses a small opening into the vein, but a solution, instead of heat, is used to close the vessel. Solutions currently in use are hypertonic saline, sodium tetradecyl sulfate, polidocanol (which lacks approval by the US Food and Drug Administration), and chromated glycerine. Hypertonic saline and chromated glycerine can be painful.
RF ablation employs a generator of RF (thermal) energy, typically operating at 2 to 6 W, attached to an ablation catheter tipped with a collapsible electrode array. The generator tracks power output, impedance time, and temperature.
Laser ablation, developed after RF ablation, also uses intravenous catheters, but they are tipped with laser diodes of 810, 940, 980, or 1,320 nm, with the 810-nm laser possibly being associated with higher incidence rates for phlebitis and discomfort.
These tools for the treatment of venous insufficiency have been developed in response to the favorable comparison of the endovascular approach with traditional methods. These tools are still in development, and research on their application and further refinement continues. Evaluation of even newer tools to treat more complex causes of reflux will also be in progress for some time.
Venous Insufficiency: Office Based Workup was presented by Neil Khilnani, MD, Cornell Vascular, Weill Medical College of Cornell University. The goal of clinical evaluation in venous insufficiency, he stated, is to guide treatment decisions by creating a map of incompetent areas. For this purpose, duplex ultrasound is essential whenever varicose veins are present.
At the 29th Annual Scientific Meeting of the Society of Interventional Radiology (SIR), held March 25 through 30, 2004, in Phoenix, a coding update was presented by Gary S. Dorfman, MD, of the University of Massachusetts Medical School Department of Radiology, National Cancer Institute, Cancer Imaging Program, Imaging Guided Intervention Branch. Dorfman emphasized the importance of proper fiscal management of practices providing endoluminal treatment of venous insufficiency, whether their facilities are found in hospitals, medical offices, clinics, or imaging centers. There is considerable variation in the cost of providing venous services and in the reimbursement received for them. Separate billing may be conducted for the professional and technical components of care, as is generally the case for hospital-based practices, or global billing may be performed, as is typical of freestanding imaging centers.
In addition to this variation, Dorfman reports that there is significant payor inconsistency concerning coverage, as well as regarding the inclusion or exclusion of particular supplies and services. At times, noncoverage by certain payors is even limited to specific techniques.
Consistent coding can play a role in reducing these difficulties and gaining proper reimbursement for services. Payor communication is also vital; practices must follow the written coding instructions of payors and, if these are absent, should request them in writing. This is still no guarantee, and even previously paid claims can be subject to payors’ requests for refunds, but there appears to be increased payor acceptance of endoluminal treatment for venous insufficiency.
In settings where Current Procedural Terminology (CPT) codes are used, applicable level-III Healthcare Common Procedure Coding System codes are S2130, for radio-frequency (RF) ablation of an existing refluxing saphenous vein, and S2131, for endovenous laser ablation of a long or short saphenous vein, with or without proximal ligation or division. Four new CPT codes are likely to become available in 2005 for RF and laser procedures inclusive of imaging guidance and monitoring.
If International Classification of Diseases codes are used, billing can be performed using 451.0, superficial thrombophlebitis; 453.8, other venous embolism and thrombosis of other specified veins; 454.x, varicose vein of lower extremities (with the mandatory fourth digit being 0, with ulcer; 1, with inflammation; 2, with ulcer and inflammation; 8, with other complication; or 9, asymptomatic); and 459.81, venous (peripheral) insufficiency, unspecified.
Practices should work with payors, in advance, to negotiate policies and payments associated with each of these codes. SIR and the interventional industry can help practices work with payors in establishing reimbursement policies.
The assessment should begin, however, with the patient’s medical history and a thorough physical examination. Cornell Vascular uses a history form that prompts the interviewer to record location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms for the patient’s problem. In addition, the form notes medical, surgical, gynecological, obstetrical, family, and social histories, along with medications and allergies. After a review of systems, the interview focuses on venous history. The presence of any comorbidities is noted, after which details are sought concerning the type and duration of the patient’s venous problem. Symptoms are recorded, along with any prior treatments (and their outcomes) and any adverse experiences associated with medical intervention for venous insufficiency. Deep-vein and superficial-vein thrombosis incidents are noted.
The physical examination that follows begins with a general examination, but focuses on venous problems. On paper, spider veins, varicose veins, swelling, eczema, pigmentation, and ulcerations are mapped, and specific problem veins are indicated on a drawing of the lower limbs. Arterial and venous circulation are evaluated, and skin complications are assessed. Digital photography is used to document the patient’s pretreatment appearance; these photographs may also be used to obtain precertification from insurance carriers.
Although varicose veins may appear to have similar locations and distributions, they may stem from entirely different incompetent pathways. Duplex ultrasound is vital to differentiation between normal and incompetent segments of veins and to the location of reflux sources. With the patient in a standing position, duplex ultrasound is used to examine the front of the lower limb from the saphenofemoral junction to the calf; then the patient faces away from the examiner and the back of the thigh is assessed from the short saphenous vein upward. Pulse-wave Doppler is the most sensitive and specific technique, according to Khilnani; color Doppler can produce an underestimation or overestimation of reflux. Manual compression of the lower veins is used to evaluate each venous segment of interest, since reflux produces a characteristic time-amplitude curve when the leg is squeezed.
Suresh Vedantham, MD, is assistant professor of radiology and surgery, interventional radiology section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis. He presented Tumescent Anesthesia for Venous Ablation: Tips and Techniques. In the absence of strategies that promote rapid, effective administration of tumescent anesthesia, he reported, the procedure is a step in endovenous ablation that can slow throughput and decrease success. If these unwanted effects are to be avoided, the interventionalist must acquire a high level of technical expertise. Vedantham stated that this expertise is directly related to the extent of the individual’s experience with endovenous ablation.
For the practice treating varicose veins, future referrals depend on patient satisfaction; satisfied patients are those whose endovenous ablations were performed painlessly, quickly, and conveniently; left no scars or skin burns; and required no sedation. Tumescent anesthesia promotes patient satisfaction because it supports these goals.
Tumescent anesthesia involves surrounding the vein to be occluded with fluid, typically a large volume of a dilute lidocaine solution buffered with sodium bicarbonate. Epinephrine may be added to promote more gradual lidocaine absorption and decrease bleeding, but epinephrine can also reduce the antimicrobial action of the lidocaine and can be hazardous if injected intravascularly, so ultrasound needle guidance is recommended. The liquid surrounding the vein serves as a heat sink and displaces the vein from the skin and nearby nerves. This, in turn, protects the patient from pain, burns, nerve injury, and thrombosis, Vedantham noted, and can also enhance probe-tip visualization. The pressure exerted by the liquid compresses the vein around the heat source, which can be especially important to achieving closure without thrombosis in the largest veins.
Given the current state of clinical expertise, the availability of advanced equipment, and the high prevalence of varicose veins, it seems clear that interventional radiologists are in a strong position to offer endovascular therapy. Unfortunately, the Yale survey1 found that 65% of interventional radiologists who did not treat varicose veins cited interdepartmental issues as the major reason. Nontreating practices also tended to be smaller, to have lower procedural volumes, and to lack physician assistants or nurse practitioners.
An opportunity for interventional radiologists to expand their practices (and revenues) clearly exists. Equipment and training will be required, but additional staff may not even be needed to launch this very promising business. 1 As Min concluded in Phoenix, the reason to start an office-based vein practice is that one cannot afford not to do so.
Kris Kyes is technical editor of Decisions in Axis Imaging News.
- Jean-Baptiste RS, Tal M. National survey to identify factors determining extent of treatment of varicose veins by interventional radiologists. Paper presented at: 29th Annual Scientific Meeting, Society of Interventional Radiology; March 30, 2004; Phoenix.
- Min R, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol. 2003;14:991-996.