Lower extremity peripheral artery disease (PAD) is a serious condition that affects millions worldwide, often causing debilitating symptoms and impacting quality of life. Traditionally, treating PAD involves open surgery, a major procedure with associated risks and longer recovery time. However, a newer approach known as endovascular revascularization has emerged, offering a minimally invasive alternative. This technique clears blockages and opens narrowed arteries in the legs by accessing them from within, requiring only a small incision to operate and clear the blockage. It’s a less complicated approach with a short recovery time.
Procedure
During the procedure, a catheter (a thin, flexible tube) is guided through the arteries using imaging techniques such as fluoroscopy (real-time X-ray) or ultrasound. Once in position, the interventional performs the necessary treatment, such as inflating a balloon to widen the artery (angioplasty) or deploying a stent to keep it open. These techniques include:
- Balloon Angioplasty: Involves inflating a balloon to widen narrowed or blocked arteries. Types of balloons used include low-profile, cutting, and cryoplasty balloons.
- Stenting: Involves placing a small mesh tube (stent) within the artery to keep it open and improve blood flow. Stents can be balloon-expandable, self-expanding, bare metal, covered, or drug-eluting.
- Atherectomy: Removes plaque buildup within arteries using specialized devices. Atherectomy techniques can be directional, rotational, or laser-based.
These procedures typically involve accessing the artery through a small incision or puncture, using catheters and imaging guidance. They may also include embolic protection, closure devices, and post-procedure imaging to ensure successful revascularization.
Coding Guidelines for Lower Extremity Endovascular Revascularization:
1. Hierarchy: Select the base code that represents the most complex service using the following hierarchy of complexity:
Atherectomy and Stent > Atherectomy > Stent > Angioplasty.
2. Multiple Lesions: Report the most complex procedure performed within the same vessel, regardless of the number of lesions treated.
3. Vascular Territories: The following are the three broad vascular territories in the lower extremity (See Figure# below).
- Iliac Territories: (each coded separately)
- Common iliac
- Internal iliac
- External iliac
- Code Selection
- Single primary code (37220 or 37221) for initial artery treated per leg.
- Up to 2 add-on codes (37222, 37223) for additional ipsilateral vessels.
- Femoral/Popliteal Territories: some text
- The entire femoral/popliteal territory in one lower extremity is considered a single vessel for CPT reporting, specifically for endovascular lower extremity revascularization.
- Code Selection
- Single code (37224-37227) regardless of procedure combination on any or all femoral and popliteal artery segments.
- No add-on codes for additional vessels.
- Tibial/Peroneal Territories: (each coded separately)
- Anterior tibial
- posterior tibial
- peroneal
- Code Selection
- Single primary code (37228-37231) for initial artery treated per leg.
- Up to 2 add-on codes (37232-37235) for additional ipsilateral vessels.
- The common tibioperoneal trunk is not considered a separate vessel for coding.
Bundled Services
CPT codes 37220-37235 for open or percutaneous endovascular revascularization procedures typically include the following services:
I. Catheterization of the selective or non-selective target vessel(s)
II. Lesion traversal
II. Radiological supervision and interpretation
IV. Embolic protection (if used)
V. Arteriotomy closure (if applicable)
VI. Imaging to document completion
These services are generally considered integral components of the endovascular revascularization procedure and are not reported separately when billing for the primary procedure (37220-37235).
Lower Limb Revascularization Coding Simplified:
Angioplasty Only:
Atherectomy (with or without Angioplasty):
Stent Placement (with or without Angioplasty):
Atherectomy and Stent Placement (with or without Angioplasty):
Note: If atherectomy and stent Placement are done for the Iliac Artery Territory
- We do not have a combination code for Atherectomy and Stent Placement for iliac artery territory.
- If performed together in a single vessel, we need to code Atherectomy (CPT 0238T) and Stent Placement (CPT 37221) separately.
Additional Notes:
- The tibial/peroneal trunk is part of distal vessel intervention in posterior tibial and peroneal arteries.
- The dorsalis pedis is part of the anterior tibial artery, and the medial malleolar artery is part of the posterior tibial artery.
- Document any diagnostic angiography performed due to limitations in prior imaging.
Reference:
- AMA CPT2024, Professional Edition.
Stay tuned with CoverSelf for detailed chapter/section-specific billing and documentation guidelines for CPT changes in 2024.
