Outfitting the Phlebology Practice

INTRODUCTION

The right equipment, supplies, and management are essential to successful patient treatment and the viability of a phlebology practice. Even though an experienced practitioner of another specialty will likely already have on hand most of the supplies necessary to perform sclerotherapy of spider and reticular veins, he or she will need to learn the administrative nuances of a phlebology practice.

Sclerosing solutions and a few disposable items are all that is necessary at the most basic level. To progress to the next level of treating varicose veins, to recognize venous reflux, and to minimize side effects, the minimum diagnostic equipment necessary is a handheld Doppler device. For thorough venous mapping and therapeutic decision-making, however, an ultrasound unit is needed. Fortunately, sophisticated portable Duplex ultrasound devices capable of detailed venous mapping and use in treatment of larger refluxing vessels are available for in-office use.

Systematic diagnostic evaluation and meticulous technique will help to reduce complications and improve results. Diagnostic reevaluation during the course of treatment or on patients’ return visits may often be necessary. Almost all patients with C2 disease or worse will require Duplex examination for adequate treatment. Many of these patients will have underlying saphenous trunk insufficiency requiring treatment beyond sclerotherapy. Physicians may choose to pursue appropriate training to perform outpatient endovenous ablation of such saphenous trunks. Investment in radiofrequency or laser ablation equipment follows. Treatment of such major trunks with foam sclerotherapy is in the investigational stage in the United States.

PATIENT EDUCATION AND DOCUMENTATION

Successful patient outcomes in a phlebology practice depend on thorough patient education and informed consent. Brochures and handouts are useful to enhance patient awareness and to answer common questions asked by patients and referring physicians. Pre- and posttreatment instruction sheets will help to ensure that the patient is prepared for treatment and increase compliance with posttreatment directions. Appendix B offers samples, including sources for brochures. Sources of patient brochures include the American Society for Dermatologic Surgery, American Academy of Dermatology, American College of Phlebology as well as private firms. A patient-oriented educational video, on DVD or watched online via website streaming, helps improve patient understanding.

Review of this information with the patient before consent is obtained allows the physician to more efficiently concentrate on evaluation of the patient and development of a treatment plan. The physician should always review the patient’s understanding of the proposed treatment and risks before actually beginning the treatment. Key points for patients to understand are that sclerotherapy is a gradual treatment process involving several treatment sessions, that it takes weeks to months to see results, and that periodic maintenance treatment is likely to be necessary for most patients. When patients return for such treatment after one or more years, it is advisable to review consent again to be sure that they understand.

MEDICAL RECORD

A properly designed record will facilitate documentation of treatment and improve the management of patients being treated for venous disease. The development of electronic medical records (EMRs) specifically for phlebology can streamline such recordkeeping. EMR is changing so rapidly that specific recommendations are impractical as industry standards evolve. Due diligence with evaluation of available software is recommended. Physicians who maintain nonphlebology practices will need systems that go beyond phlebology-only software.

For physicians with paper records, separate grouping of vein treatment documents allows more efficient patient management. The record should include pertinent history and physical findings, the physician’s assessment, plan, and diagnostic tests recommended. A written estimate of costs should be signed by the patient. Results of vascular diagnostic testing are included in the venous record. Accurate recording of each treatment on a schematic leg diagram details injection locations and solutions used, including amount, concentration, and form (foam versus liquid). Table 25-1 lists the key components of the phlebology chart, and samples of these documents are found in Appendix B. Different colors record specific solutions and concentrations used in the authors’ practice.

TABLE 25-1
Components of the Phlebology Chart

• Registration form

• History and physical examination

• Assessment and plan

• Photographic documentation

• Treatment estimate

• Diagnostic testing results

• Treatment and progress notes

• Consent form

Thorough photographic documentation is essential. Prior to initial treatment, as well as subsequent maintenance treatments, recumbent and upright images should be taken. Digital camera systems have largely replaced the use of film. For many years, the authors successfully used floppy discs recording up to 28 images each. Each patient’s chart had its own immediately accessible disc. This technology is now outmoded through lack of industry support; there are no new cameras and existing ones are difficult to repair. Fortunately, many digital photographic systems are available to choose from online, and many EMR systems allow for digital image storage.

A consent form written specifically for phlebology, with appropriate sections for sclerotherapy, laser, and endovenous ablation, is very helpful for optimum patient understanding. Printed posttreatment instructions are given to the patient. Even as practices transition to EMRs, there will still be a need for printed patient instructions.

BOOKKEEPING AND INSURANCE CONSIDERATIONS

Choices for computerized billing software abound in 2011, many incorporated in EMR systems. Rapid technological advances preclude recommendation of specific billing software. For practices that participate with insurance, a streamlined system to obtain insurance preauthorization for medically indicated sclerotherapy and endovenous ablation is important. As of 2011, U.S. physicians may decide for themselves regarding participation with private insurance for reimbursement of medically necessary vein treatment. Economic conditions and the unclear nature of U.S. healthcare reform pose challenges for all physicians, with the future of insurance reimbursement for venous procedures unclear. Generally, reimbursement has followed a downward trend for both sclerotherapy and endovenous ablation, reinforcing the need for efficient and cost-effective practice management. Nearly all insurance companies consider treatment of leg telangiectasias as cosmetic. Patients should be advised by staff when scheduling appointments that they are responsible for payment for cosmetic treatments. Cost of treatment should be understood and accepted by patients before they begin treatment.

Although physicians make an assessment and recommendation of medical necessity of vein treatments, insurance companies determine actual “medical necessity” of venous treatment. Each company has its own policies regarding payment or nonpayment, and the contractual amounts of reimbursement and patient copayments. In most states in 2011, nonparticipating physicians may charge a patient directly for treatment; an insurance claim may then be filed by either the physician or the patient, for the patient’s eventual partial reimbursement (or not, depending on the patient’s insurance policy). Many insurance companies restrict or have eliminated coverage of sclerotherapy of varicose veins. Physicians must know the specific guidelines of each plan with which they participate.

Insurance companies’ guidelines are often available online. Knowledge of plans’ requisite patient history, physical, and ultrasound findings will streamline the strongly recommended and usually necessary preauthorization process. For preauthorization, most insurance companies require pretreatment photographs that show the varicose veins to be treated. Unfortunately, many varicosities do not photograph well, especially in overweight patients. In this situation, supporting abnormal test data (Duplex ultrasound) is crucial to document the patients’ problem. Most plans will not cover sclerotherapy if there is untreated saphenous reflux in the affected limb. Another common requirement is that a patient’s venous signs and symptoms have not improved after six months’ use of compression stockings. The medical record must document this.

If insurance coverage is being considered, it is imperative to obtain written, specific preauthorization of the planned treatment. Individualized modification of EMR and billing systems, with template use, can ease the administrative burden. The number of allowed treatment sessions should be noted in the chart, as well as the expiration date of the authorization. Review the insurance company’s decision with the patient so that they have a full understanding of their financial obligation. Stay abreast of the frequent changes in regulations and insurance company guidelines. Most insurance companies in the United States in 2011 consider sclerotherapy of saphenous trunks as experimental and as such excluded. Obviously, cosmetic, nonmedically necessary treatment should not be billed to insurance companies; unfortunately, some physicians do fraudulently file such claims. Nor should expensive technology be overused when unnecessary.

CURRENT PROCEDURAL TERMINOLOGY CODES FOR SCLEROTHERAPY

The current procedural terminology (CPT) terminology codes for sclerotherapy are as follows:

1. 36468: Single or multiple injections of sclerosing solutions, spider veins (telangiectasia), limb, or trunk.

2. 36469: Single or multiple injections of sclerosing solutions, spider veins, face.

3. 36470*: Injection of sclerosing solution, single vein, leg.

4. 36471*: Injection of sclerosing solution, multiple veins, same leg.

5. 36471-50*: Bilateral injection of sclerosing solution, multiple veins, two legs.

Although the nuances of CPT coding are beyond the scope of this textbook and may be irrelevant to the international reader, it is imperative that U.S. physicians and their staff maintain up-to-date knowledge of CPT. The asterisk (*) means that the surgical code listed above includes only the surgical procedure of sclerotherapy. This means that an appropriate evaluation and management (E&M) code (if “significant identifiable services” were actually provided in addition to the procedure), for a new or established patient, with the modifier “–25” may be theoretically added to the bill. However, this terminology has no bearing on whether or not an insurance company will actually pay for the added E&M visit charge.

PRETREATMENT EVALUATION

Basic in-office diagnostic tests are screening continuous-wave Doppler ultrasound and Duplex ultrasound examination of the venous system. A handheld Doppler unit may suffice for screening of superficial venous insufficiency, but Duplex ultrasound remains the gold standard for such diagnosis. A handheld Doppler was typically the first device purchased as a physician progressed from the occasional treatment of isolated telangiectasias to treatment of reticular and varicose veins. The understanding and use of Doppler to diagnose venous reflux is critical to making the leap from a sclerotherapy novice to a skilled practitioner. To the physician practicing sclerotherapy, the Doppler is as essential as a stethoscope is to an internist. Several manufacturers can be found online, including Huntleigh, Summit, and Imex (Figure 25-1). Detection of venous reflux in the zones of saphenous trunk influence is critical to the successful treatment of leg veins. Doppler examination is a helpful start in that process and should be followed by detailed venous Duplex mapping when reflux is detected.

FIGURE 25-1 Typical equipment used for diagnostic physiologic testing. A. Three inexpensive handheld Doppler units by Huntleigh, Imex, and Elcat. B. Digital photoplethysmograph (DPPG), photo courtesy of Elcat GmBH.