A Hodgepodge of Issues Surrounding Reimbursement

by Joseph Zygmunt, RVT, RP hS, and AJ Riviezzo, MBA

VEIN Magazine Winter 2014


“Hey, I saw an ad in the paper for a ‘free vein consultation.’ I think I want to do that too—it will attract new patients like crazy!” What do you think of this as a method to attract patients?


This is a question that physicians pose frequently. Unfortunately, many have no understanding of the implications of this practice, and in other instances it’s an amazing thing to realize how much “rule bending” is going on out there. Ultimately, a physician should understand what the implications of this practice are and make an informed decision about taking this risk and avoiding the pitfalls of this activity. Some guidelines are presented below.

A large number of practices offer a free consultation in their advertising. It is a great way for both parties, the practice and the patient, to size each other up. The patient is able to delay the purchasing decision and allows for some information to be exchanged, ensuring they are an educated consumer

We strongly recommend that the free consultation is just an “educational visit.” The patient should be informed over the telephone that they will receive 10 to 15 minutes of the physician’s or staff’s time to review any questions they may have about their venous disease. Asking the patient to write down their questions prior to the appointment is a fantastic way to have the patient more involved and more invested in their treatment options and decisions.

The primary concern is that many practices are treating this visit as a quasi-initial patient visit. They are not only gathering the patient self-report documents, but also documenting what is essentially a history and physical. Some practices even perform a mini-diagnostic ultrasound as well; others use this mini-diagnostic ultrasound to seek medical necessity on an incomplete exam. The concerns with this are twofold. The first issue-is that the practice will be bringing the patient back at a later time to actually complete the remaining portions of the history and physical. Medicare and other auditing agencies can make a strong argument that the initial patient visit was during the free consult and not the date the history and physical was completed. The second concern is that Medicare could consider the “free” care–examination and ultrasound–as an inducement, which is not allowed. Additionally consider that if you perform a service during a free visit and a similar service during a billable office visit, what distinctions are there between the two visits? In other words, are the experiences similar or overlapping? Lastly, be careful of advertising a free visit and then converting it to a “paid” visit; this can cause irritation with both advertising bait-and-switch guidelines and your medical board.

The good news is that Medicare does allow for an educational visit as do all commercial payers. As such, I recommend that the documentation for the visit is reflective of this educational concept.

A quick tip:

Once the educational visit is complete, the patient may want to stay and complete other services. If this is the case, have the patient sign a document noting that they understand the free consultation has been completed, that they have made the choice to move forward, and are now receiving medical services which will be billed to their insurance carrier. These additional services could include a full history and physical and/or diagnostic ultrasound. As with many aspects of vein therapy, with time, the patient’s memory of what was said–or how bad their veins were–seems to fade, yet they always remember that all the services that initial day were all supposed to be free.


Those who have been in the field of phlebology remember that prior to the current RFA and laser ablation codes, a generic code of 37204 was initially used for vein ablation. That changed in 2005 with the addition of CPT codes 36475-36479. Here we are in 2014, and coding changes again will affect vascular embolization procedures. This information, accessed from radadvocate.com or the American College of Radiology (ACR) website, reflect the changes in coding and the language implemented for 2014 with regard to venous embolization coding.


“Embolization codes have undergone significant changes in 2014. Four new codes replace existing embolization codes of 37210 (uterine fibroid embolization) and the non-CNS, non-head embolization code, 37204…The major distinction in the new codes is the reason for embolization (eg, AVMs, varices, hemorrhage, tumor, ischemia, infarct, etc.). These codes also are defined by arterial or venous [emphasis added] and once again include all radiological supervision and interpretation required to perform the procedure.”

[Deleted] Codes

37204 Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck (see 37241-37244)

New Code

37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

(For sclerosis of veins or endovenous ablation of incompetent extremity veins, see 36468-36479)
(Do not report 37241 in conjunction with 36468, 36470, 36471, 36475-36479, 75894, 75898 in the same surgical field) [emphasis added]

The hodgepodge of information presented is for informational purposes to update those who may not be aware of or be familiar with these aspects of reimbursement in phlebology setting. A practicing physician should rely on the advice and counsel from their advisors and consultants on matters regarding these or other compliance-related matters.