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By Katherine Kozlowski, medical author and contributor to Vein News and www.VeinsVeinsVeins.com

The 2020 update for the CEAP classification has added new coding guidelines including, among others, the “r” nomenclature for recurrent varicose veins in a patient who has been previously treated for varicose veins (C2r).
 
Other additions are 1) the use of the CEAP clinical stage C4c for corona phlebectatica and 2) recurrent active venous ulcer C6r. 

A recent editorial in Phlebology by Neil Khilnani MD and Alun H Davies MD raises the question regarding "complications of venous disease", namely phlebitis, hemorrhage, or cellulitis.
 
The authors of the editorial state that potential additions to the C component of the CEAP classification should be nomenclature for a patient who presents with acute bleeding from a varicose vein or a patient with cellulitis or a patient with phlebitis. 

Here are the Updated 2020 CEAP classification guidelines:

1. C0: Without any visible or palpable signs of disease.

2. C1: Telangiectasia or reticular veins

3. C2: Varicose veins

   1. C2r: Recurrent varicose veins

4. C3: Edema is present

5. C4: Changes in skin and subcutaneous tissue

   1. C4a: Pigmentation or eczema

   2. C4b: Lipodermatosclerosis or atrophie blanche

   3. C4c: Corona phlebectatica

6. C5: Healed ulcers

7. C6: Active ulcers

   1. C6r: Recurrent active venous ulcer
      
      
      The updates are published by Fedor Lurie, Marc Passman, Mark Meisner MD, Elna Masuda, Harold Welch, Ruth Bush, John Blebea, Patrick H Carpenter, Marianne De Maeseneer, Anthony Gasparis,  Nicos Labropoulos, William A Marston, Joseph Rafetto, Fabricio Santiago, Cynthia Shortell, Jean Francois Uhl, Tomasz Urbanek, Andre van Rij, Bo Eklof, Peter Glovickzi, Robert Kistner, Peter Lawrence, Gregory Moneta, Frank Padberg, Michel Perrin, and Thomas Wakefield. 
      
      The article is published in J Vasc Surg Venous Lymhat Disord 2020; 8(3): 342-352. 
      
      
      The Phlebology Editorial PDF file:  
      
      https://higherlogicdownload.s3-external-1.amazonaws.com/PHLEBOLOGY/d433103e-028e-465f-b5c3-ce94ecb0fd65_file.pdf?AWSAccessKeyId=AKIAVRDO7IEREB57R7MT&Expires=1613689350&Signature=QqtivShU75xFX4UD7AgAyK5DwYo%3D

Dr. Karamanoukian's comment:  this subclassification may help as insurers need clarity that the reason for intervention is not purely for swelling or the presence of varicose veins, but rather, an emergent or urgent medical condition (hemorrhage from veins) that is potentially dangerous.