Get a Leg Up on Lower Extremity Revascularization Coding

Get a Leg Up on Lower Extremity Revascularization Coding

Anatomy is key, as is understanding what’s included in the intensive services.

Coding for endovascular revascularization of the lower extremities seems daunting, but is made easier if you understand that the codes are hierarchical, and angioplasty is always included with more extensive services. It’s also important to master lower extremity vascular anatomy.

How Revascularization Is Achieved

Endovascular revascularization is performed to restore blood flow by removing an occlusion (or blockage, such as a buildup of plaque) within a vessel. Methods include angioplasty, stent placement, and atherectomy, and may be used individually or in combination to achieve revascularization:

Angioplasty involves inserting a tube, with a balloon attached on one end, into the artery. The balloon is inflated at the site of the occlusion to push it outward, widening the opening and improving blood flow. The balloon is then deflated and removed. There are various types of balloon angioplasty (e.g., low-profile, cutting balloon, cryoplasty): for coding purposes, all are treated the same.

A stent is a mesh tube that helps to keep an artery open. Like a balloon, it is maneuvered into place and “opened” at the site of an occlusion to restore blood flow. Unlike a balloon, a stent is left in place. There are several types of stents (e.g., balloon-expandable, self-expanding, bare metal, covered, drug-eluting): for coding purposes, all are treated the same.

Whereas angioplasty and stent placement push plaque outward to improve blood flow, Atherectomy uses a cutting device to remove plaque from the vessel walls. The cutting device used in atherectomy varies (e.g., directional, rotational, laser): for coding purposes, all are treated equally.

Get to Know the Vascular Territory

CPT® codes 37220-37235 describe lower extremity endovascular revascularization services performed for occlusive disease (see the accompanying sidebar “CPT® Codes for Lower Extremity Endovascular Revascularization” for code descriptors). These codes divide the arteries of the lower extremities into three vascular territories.

1. The iIliac territory includes the common iliac, internal iliac, and external iliac arteries.

Report a single primary code (37220 or 37221) for the initial iliac artery treated in each leg. If other iliac vessels are treated in the same leg, report these interventions using the appropriate add-on codes (37222, 37223).

2. The femoral/popliteal territory is considered a single vessel for CPT® reporting when using 37220-37235.

Report a single interventional code (37224, 37225, 37226, 37227), no matter what combination of angioplasty/stent/atherectomy is applied to any segments, including the common, deep, and superficial femoral arteries and the popliteal artery. There are no add-on codes for additional vessels treated in the femoral/popliteal territory.

3. The tibial/peroneal territory includes the anterior tibial, posterior tibial, and peroneal arteries.

Use a single primary code (37228, 37229, 37230, 37231) for the initial tibial/peroneal artery treated in each leg. If other tibial/peroneal vessels are treated in the same leg, report these interventions using the appropriate add-on codes (37232-37235). You may report up to two add-on codes in this territory, depending on whether two or all three tibial/peroneal vessels are treated. Use the add-on codes only for different vessels, not for distinct lesions in the same vessel.

For a quick reference of the above rules, see Table 1.

Watch for Bundled Services

All codes in the range 37220-37235 describe open or percutaneous procedures, and include specific services/procedures that may not be reported separately, including:

  • Selective or non-selective catheterization of the target vessel(s)
  • Traversing the lesion
  • Radiological supervision and interpretation directly related to the intervention(s)
  • Embolic protection, if used
  • Closure of the arteriotomy by any method
  • Imaging performed to document completed intervention

If a lesion extends across the margins of two vascular territories, but can be opened with a single therapy, this intervention is reported with a single code despite treating more than one vessel and/or vascular territory.

For example, a stenosis extends from the internal iliac artery into the distal external iliac artery. A single stent is placed for the entire stenosis. This procedure is reported as a single stent placement in the iliac artery (37221).

Coding Interventions in
More than One Extremity

When the same territory(ies) in both legs are treated during the same session, a modifier is required. Use modifier 59 Distinct procedural service (or the appropriate Medicare “X{EPSU}” modifier) to denote that different legs were treated, even if the mode of therapy is different.

For example, a recent angiography shows a total occlusion of the femoral arteries, bilaterally, and the patient is admitted for intervention. Percutaneous puncture of the popliteal artery is followed by sheath placements across the popliteal artery to the proximal cap of the anterior tibial artery, with femoral angioplasty. Both legs are treated similarly. Report 37224 for the initial leg and 37224-59 for the other leg.

Extensive repair or replacement of an artery (e.g., 35226 Repair blood vessel, direct; lower extremity or 35286 Repair blood vessel with graft other than vein; lower extremity) may be reported additionally, when performed and appropriately documented.

Mechanical thrombectomy and/or thrombolysis in the lower extremity vessels are sometimes necessary to aid in restoring blood flow to areas of occlusive disease, and are reported separately.

CPT® Codes for Lower Extremity
Endovascular Revascularization

37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

37221      with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

+37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

+37223      with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

37225      with atherectomy, includes angioplasty within the same vessel, when performed

37226      with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37227     with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

37229      with atherectomy, includes angioplasty within the same vessel, when performed

37230     with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37231     with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

+37233     with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

+37234     with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

+37235     with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

The lower extremity revascularization codes are hierarchical, whereby more intensive services are inclusive of less intensive services. This means that if percutaneous transluminal angioplasty (PTA) is performed with atherectomy or stent placement (or both), do not separately report the PTA; it’s included as part of the more extensive procedure, as illustrated in Table 1.

When appropriate, you may report more than one code in the range 37220-37235 per territory treated, but you may report no more than one code in the range 37220-37235 per vessel treated (reference Table 1).


Sivaraj Ramesh, CPC, CEMC, CCS, is an assistant manager for Global Healthcare Billing Partners Pvt. Ltd. He has a professional degree in physical therapy, a master’s degree in psychology, and has completed Lean Six Sigma Black Belt.  Ramesh has more than 11 years’ experience in medical coding, with multispecialty expertise in radiology, evaluation and management, and surgery.

Leave a Reply

Your email address will not be published. Required fields are marked *