Lower Extremity Revascularization Coding and its

Relationship to Vascular Access Procedures

ASDIN Coding University

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New Concept

• Prior to 2011, angioplasty and related procedures in the lower extremity were coding in the same manner as those in the upper

• In 2011 the Lower Extremity Revascularization (LER) coding system was introduced

• While not designed for dialysis vascular access, some of its principles do have an effect

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Generalities About the LER System

• The arteries of the lower extremity are divided into 3 vascular territories:– Iliac – Femoral/popliteal – Tibial/peroneal

• Each territory has a unique set of codes assigned

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Hierarchical System of Coding

• The series of codes 37220-37235 are to be used to describe lower extremity endovascular revascularization services performed for occlusive disease

• These lower extremity codes are built on progressive hierarchies with more intensive services (stenting, atherectomy) being inclusive of lesser intensive services (angioplasty)

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Example

• The lowest level code is for angioplasty • If this is followed by stent placement, another code

is recorded that includes the lower level• In this instance only one code would be used to

represent both procedures

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All Inclusive• Each of the codes used is all inclusive except for the

diagnostic angiogram which is coded separately • Each individual code includes:– Non-selective cannulation– Selective catheterization– Radiological supervision and interpretation (RS&I)– Embolic protection if used– Closure of the arteriotomy by any method– Imaging performed to document completion of the intervention

in addition to the intervention(s) performed.

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Iliac Vascular Territory

• The iliac territory is divided into 3 vessels: – Common iliac– Internal iliac– External iliac

• Lesions in each of these vessels can be coded for a maximum of three

• A single code is used for each vessel treated

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Codes for the 1st Vessel Treated

• For the first artery with a lesion that is treated:– 37220 - Revascularization, endovascular, open or

percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

• If a stent is required, this code would be dropped in favor of:– 37221 - With transluminal stent placement(s), includes

angioplasty within same vessel, when performed

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Codes for Additional Arteries in Iliac Territory

• +37222 –angioplasty (List separately in addition to code for primary procedure)

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

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Important Principle• Up to 2 add-on codes can be used in a unilateral iliac

vascular territory since there are 3 vessels which could be treated

• Add-on codes are used for different vessels, not distinct lesions within the same vessel

• Multiple lesions within the same vessel would receive a single code for all

• If lesions are also present in the contralateral leg, these would be coded independently, this system relates to a single extremity

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Femoral/Popliteal Vascular Territory

• The entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for coding purposes

• A single code is used no matter what combination of angioplasty/stent/atherectomy is applied to any segments, including the common, deep and superficial femoral arteries as well as the popliteal artery

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The Codes• 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

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Important Principle

• Since only a single vessel can be coded, there are no add-on codes for additional vessels

• Because only 1 service is reported when 2 lesions are treated in this territory, the most complex service (e.g., highest level code) should be recorded

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Tibial/Peroneal Territory

• The tibial/peroneal territory is divided into 3 vessels:– Anterior tibial artery– Posterior tibial artery– Peroneal artery

• Lesions in each of these vessels can be coded for a maximum of three

• A single code is used for each vessel treated

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The Codes for the 1st Vessel Treated

• 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

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Codes for Additional Arteries in This Territory

• +37232 – each additional vessel; transluminal angioplasty

• +37233 – atherectomy, includes angioplasty within the same vessel

• +37234 - stent placement(s), includes angioplasty within the same vessel

• +37235 - transluminal stent placement(s) and atherectomy, includes angioplasty

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More than two Vessels With Territory

• If an additional lesion is present in a third vessel within the territory, the appropriate add-on code would be used with a 59 modifier attached

• A maximum of three individual codes, one for each vessel, can be recorded

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Lesion that Bridges Territories

• If a lesion extends across the margins of one vascular territory into another, but can be opened with a single therapy, this intervention should be reported with a single code despite treating more than one vessel and/or vascular territory

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Additional Points

• When the same territor(ies) of both legs are treated in the same session, modifiers should be used to describe the interventions – Use modifier 59 to denote that different legs are being

treated, even if the mode of therapy is different

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

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LER Affects on Vascular Access Coding

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Arterial Angioplasty in Lower Extremity Access

• The arterial anastomosis of the vascular access is classified as the arterial portion of the access

• If an angioplasty is performed in this region in the lower extremity, LER coding system must be used

• This will generally be the femoral-popliteal territory– The code for angioplasty alone – 37224– If a stent is also performed – 37226 (as single code)

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Cannulation/Catheterization• If a thigh graft has an arterial lesion that is treated:– The non-selective cannulation code should not be recorded,

it is bundled with the LER code for the arterial angioplasty procedure

– The angiogram code would be record separately (75791)

• If a second non-selective cannulation is performed it should be coded as 36147, it is the 1st codable cannulation of the access – with a 59 modifier– The angiogram code would need to be dropped because it is

now included in the cannulation code

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Important Note• This document is for informational purposes only and

should serve as a guideline for appropriate coding.• The ultimate responsibility for correct coding

/documentation remains with the provider of service. • ASDIN makes no representation, warranty, or guarantee

that this compilation of information is error-free, nor that the use of this guide will prevent differences of opinion or disputes with CMS or any other carrier.

• ASDIN will bear no responsibility or liability for the results or consequences that may grow out of the use of this guidance.

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