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Procedure Name
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CPT Code
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Description
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Affected Vein Being Treated
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2nd Affected Vein Being Treated
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Performing Physician
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Performing Physician
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Registered Vascular Specialist/ Technologist
• • •
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Service Location
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Location
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Brief History
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Operation
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Operation 2nd Vein
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Location
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2nd vein Location
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Operation Aborted Selection
• • •
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Anesthesia
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Pre-operative Diagnosis
• • •
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Indication for Procedure
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Measured Reflux of Affected Vein Being Treated at SFJ/SPJ
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Measured Reflux of Affected Vein Being Treated at SFJ/SPJ
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Measured Reflux of Affected Vein Being Treated at Prox Thigh
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Measured Reflux of Affected Vein Being Treated at Mid Calf
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Measured Reflux of Affected Vein Being Treated at Mid Thigh
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Measured Reflux of Affected Vein Being Treated at Knee
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Measured Reflux of Affected Vein Being Treated at Mid Calf
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Diameter of Vein Being Treated
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At SFJ/ SPJ
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At SFJ/ SPJ
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At Prox Thigh
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At Mid Thigh
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At Knee
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At Mid Calf
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2nd vein At Mid Calf
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Symptoms Experienced
• • •
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Procedure
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Procedure Description
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Post-Operative Documentation
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Total Treatment Time (minutes)
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Total Treatment Time (seconds)
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2nd Vein Total Treatment Time (minutes)
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2nd Vein Total Treatment Time (seconds)
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Total Treatment (cycles)
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2nd Vein Total Treatment (cycles)
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Total Tumescent Used (number)
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Post-Closure Ultraround Assessment
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Post Closure Ultrasound Assessment
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Plan
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Follow up
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Patient Education
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Instructions
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Billing
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Billing Services
• • •
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Modifier for Aborted Case
• • •
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Consent
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Prior Authorization
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HPI Note
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