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ZHealth Publishing eLearning Coding Series 2019 - CPT Coding for Lower Extremity Arterial Endovascular Revascularization By David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Revascularization procedures for occlusive disease of the lower extremity arteries have specific codes to describe the major interventions performed to restore blood flow in the leg. Revascu- larization includes angioplasty, atherectomy, and vascular stent placement. The same procedure code is utilized whether it is an open or a percutaneous revascularization. Topics Covered: General Coding Rules General Coding Rules 1 There are coding guidelines that are common ifier will be necessary to demonstrate that this to all three lower extemity vascular territories was performed at a seperate session). Iliac Artery 2 Revascularization (iliac, femoral/popliteal, and tibial/peroneal). One guideline is the bundling of services into As with all vascular interventions, if the patient Femoral/Popliteal Artery 7 the revascularization procedure codes. Cath- has had a diagnostic angiogram [whether Revascularization eter placement, imaging guidance, placement catheter-based or computed tomographic Tibial/Peroneal Artery 10 of an embolic protection device, post-inter- angiography (CTA)] and is referred for the Revascularization vention follow-up imaging, and closure device intervention, a diagnostic angiogram is not Revascularization in 13 placement are bundled into all of the lower ex- separately reported. If, however, a diagnostic Multiple Territories tremity endovascular revascularization codes. angiogram is clinically indicated it may be re- Summary 16 In addition, there are combination codes to ported separately. Documentation must sup- describe multiple revascularization techniques port the need for a repeat diagnostic angio- performed in the same vessel/territory. gram, when performed. All the lower extremity endovascular revascu- Interventions other than angioplasty, ather- larization codes are utilized for both open and ectomy, and stent placement are reported percutaneous procedures. There are not sepa- separately following the standard guidelines rate codes based on the approach in the lower for use of these codes. When treating bypass extremities. grafts, the proximal anastomosis, distal anastomosis, and the graft are all considered one Since selective catheter placement in the vessel for coding purposes. Also, for coding lower extremity being treated is included in purposes, a “laser angioplasty” (which com- the revascularization code, all catheter place- bines laser atherectomy and balloon angio- ments along the route to that intervention are plasty) is considered an atherectomy. also included. For example, if the left lower extremity is revascularized from a right femoral The iliac, femoral/popliteal, and tibial/perone- artery access site, catheter placement in the al vascular territories each have their own set right iliac artery, aorta (even if separate imag- of codes, and each is reported independently ing of the right iliac or aorta is performed), and of the others. Each territory will be discussed in the left leg is included in the revasculariza- individually and then together to demonstrate tion code for the left leg. how complex multi-vessel revascularization procedures are reported. Codes 37220-37235 Catheter placement for lower extremity throm- are used for treatment of occlusive disease bolysis at a separate session on the same date only. They are not used for other reasons for of service as an angioplasty/atherectomy or intervention such as aneurysm repair. stent placement is separately coded (-XE mod- Page 2 Iliac Artery Revascularization The iliac artery vascular system includes the common 37221) is reported per unilateral iliac territory. The iliac, internal iliac, and external iliac arteries. The fol- codes are unilateral, so each leg is coded indepen- lowing CPT codes are available to report revascular- dently. When the procedure is performed on both ization in the iliac territory: lower extremities, they are either reported once with a -50 (bilateral) modifier or twice (with anatomical • 37220 – Revascularization, endovascular, open modifiers, or with a -76 or -XS modifier appended to or percutaneous, iliac artery, unilateral, initial ves- one of them). The Centers for Medicare and Medicaid sel; with transluminal angioplasty Services (CMS) has indicated that the bilateral modi- • 37221 – Revascularization, endovascular, open or fier may be appended. The American Medical Asso- percutaneous, iliac artery, unilateral, initial vessel; ciation has instructed to report the code twice with with transluminal stent placement(s), includes a -59 modifier appended. Payment should be the angioplasty within same vessel, when performed same either way, but CMS is trying to reduce the use • 37222 – Revascularization, endovascular, open of modifier -59. Be sure to check with your specific or percutaneous, iliac artery, each additional ipsi- payer as to its preference. lateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary The initial vessel code should reflect the most com- procedure) plex procedure performed in the territory. Stent with • 37223 – Revascularization, endovascular, open or without angioplasty is more complex than angio- or percutaneous, iliac artery, each additional plasty alone. When a stent is placed in one of the ipsilateral iliac vessel; with transluminal stent unilateral iliac arteries, code 37221 is reported as the placement(s), includes angioplasty within the initial vessel. Code 37220 (initial iliac angioplasty) is same vessel, when performed (List separately in not reported if a stent has been placed in any of these addition to code for primary procedure) vessels on the same side (the angioplasty is reported • 0238T – Transluminal peripheral atherectomy, with code 37222). If a stent is not placed in any of the open or percutaneous, including radiological su- vessels, and an angioplasty is performed, code 37220 pervision and interpretation; iliac artery, each vessel is reported for the angioplasty in the initial vessel of that unilateral iliac territory. The iliac vascular system is unique from the other two lower extremity systems in that there is a sepa- When interventions are performed in more than one rate CPT code for reporting atherectomy (0238T), iliac vessel, the intervention in one artery is reported when performed. Atherectomy is bundled into the with the initial vessel code and the additional vessel femoral/popliteal and tibial/peroneal revasculariza- code is reported for any additional iliac angioplasty tion codes. While iliac atherectomy has its own code, and/or stent placement performed. Only two “addi- which is reported in addition to angioplasty or stent tional vessel” codes may be reported per iliac territory, placement in an iliac artery, it is reported with a Cat- as only three iliac arteries are recognized for coding egory III CPT code. Category III CPT codes are for re- purposes (common iliac artery, internal iliac artery, porting new and emerging technology. Some payers and external iliac artery). Any branch of the internal do not reimburse these codes for this reason. iliac is part of a single code for the entire internal iliac artery distribution. Stent placement supersedes an- The iliac revascularization codes are differentiated gioplasty in the hierarchy of revascularization coding, as the initial vessel intervention (37220 and 37221) so if a stent is placed in any of the three iliac arteries and each additional vessel intervention (37222 and report the stent placement as the initial vessel (37221), 37223). The two “initial vessel” codes describe an- regardless of whether that vessel was treated first or gioplasty alone (37220) and stent placement (with last. Note that code 37221 is described as including or with or without angioplasty) (37221). The “each angioplasty when performed. This means that code additional vessel” codes are also differentiated as an- 37221 is reported when a stent is placed in a vessel gioplasty alone or stent placement (with or without that also is treated with angioplasty or when only a angioplasty). Only one initial vessel code (37220 or stent is placed and angioplasty is not performed. Page 3 In the iliac territory, atherectomy is reported in addi- deployment zone. Placement of a stent graft for an- tion to any other intervention, when performed. CPT eurysm, pseudoaneurysm, arteriovenous malforma- Category III code 0238T is utilized to report ather- tion, or trauma is not reported with the revasculariza- ectomy in an iliac artery and is reported per artery tion codes (37221 or 37223). There are distinct codes treated. It may be reported up to three times in one for reporting stent graft placement for these indica- extremity, as three distinct iliac arteries (the common, tions in the aorta and in the iliac arteries. Code 37236 external, and internal iliac arteries) are recognized for is used for stent graft placement to treat an aneurysm coding purposes. The iliac atherectomy code does not below the iliac artery. include catheter placement, so if only an iliac atherectomy is performed, report the catheter placement(s) If a contiguous lesion across two of the described separately. If any other revascularization is performed iliac arteries is treated with one revascularization, it in that extremity, in the same or in a different vascular is reported as one procedure and reported with one territory, do not report the catheter

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