Procedure coding
In European countries, procedure coding for varicose treatment is well-established, and it is different for surgical (e.g., phlebectomy, crossectomy, stripping) and endovenous occlusion procedures. For example, in the German classification of medical operations and procedures (OPS), there is a specific sub-chapter 5-385 “Removal and closure of varicose veins”, which includes codes for sclerotherapy (code 5-385.0), endovenous radiofrequency ablation (code 5-385.b), endovenous laser therapy (code 5-385.g), endovenous rotational ablation with sclerotherapy (code 5-385.c), endovenous occlusion with glue (code 5-385.e), phlebectomy (code 5-385.9), crossectomy (code 5-385.8), and stripping. The codes differ depending on the treated lower extremity vein (the 6th digit in the code number).
Payment mechanism
The payment model for varicose vein treatment depends on the setting where the procedure is performed.
In hospital settings, the payment model for varicose vein treatment in most European countries is a diagnosis-related group (DRG). The DRG allocation differs depending on the type of procedure (open surgical or endovascular), the stage of varicose vein disease (with different DRGs and higher tariffs for procedures performed in ulceration), and the laterality of intervention. For example, in England, the HRG allocation for endovenous occlusion procedures differs depending on the laterality of interventions: HRG YR31Z “Percutaneous Transluminal, Laser or Radiofrequency Ablation, of Unilateral Varicose Veins” with a tariff of £1,154 or HRG YR30Z “Percutaneous Transluminal, Laser or Radiofrequency Ablation, of Bilateral Varicose Veins” with a tariff of £1,789.
The payment model for day case and outpatient specialist services, where varicose vein treatment is typically performed, varies between European countries: in England, France, the Netherlands, and countries of the Nordic region, the procedures are reimbursed solely via the DRG mechanism, whereas in Germany, Italy, Switzerland, the radiotherapy preparation and delivery services are reimbursed via a fee-for-service model via country-specific catalogs for outpatient specialist services.
For example, In day case and outpatient settings, open surgical procedures for varicose vein treatment are considered under chapters 31 and 36 of the EBM catalog. These chapters indicate interventions that can be performed, such as hospital day surgery, regulated by the so-called AOP contract. Several open surgical and endoscopic procedures for varicose vein treatment are grouped into five EBM categories for vascular interventions depending on the OPS coding with a tariff ranging from €141 to €545. In addition to the procedural fee, supplementary fees for anesthesia, intra- and post-operative monitoring, and treatment can be charged.
In most European countries, the devices for varicose vein treatment do not attract additional (top-up) reimbursement, which is paid in addition to the DRG tariff. One of the exceptions is England, where radiofrequency, cryotherapy, and microwave ablation probes and catheters are included in the High Cost Devices List and reimbursed in addition to the HRG tariff.
Policy considerations
Varicose vein treatment can be subject to specific policies from payers or decision-makers in the countries where such frameworks exist.
In England, the treatment of varicose veins is excluded from specialized vascular services and commissioned by Integrated Care Boards (ICBs) in line with local policy documents. For example, according to the Varicose Veins Clinical Commissioning Policies of Cheshire and Merseyside ICB and Northwest London ICB, surgical interventions (including endothermal ablation, sclerotherapy, and open surgery) are routinely commissioned in patients with any of the following: symptomatic primary or recurrent varicose veins, lower‑limb skin changes, superficial vein thrombosis, venous leg ulcer.
Health technology assessment
Due to the rapid development of technologies, devices for varicose vein treatments frequently become a subject of HTA. For example, the National Institute for Health and Care Excellence (NICE) published several interventional procedures guidance (IPGs) for different methods of varicose vein treatment, including radiofrequency ablation, transilluminated powered phlebectomy, endovenous laser treatment of the long saphenous vein, ultrasound-guided foam sclerotherapy, cyanoacrylate glue occlusion and endovenous mechanochemical ablation for varicose veins. All methods, except for transilluminated powered phlebectomy, received positive recommendations by NICE (evidence on the safety and efficacy of procedures was adequate to support their use).
Future challenges
Varicose vein treatments have established reimbursement and funding in most European countries. New health technology assessments are likely to be relevant only for technologies with different mechanisms of action or the use of novel materials. Procedures and devices for varicose vein treatment with unique designs, alternative energy sources, or novel materials for occlusion might require the development of procedure codes, establishing reimbursement and funding, and obtaining HTA recommendations.
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