Lower Extremity Revascularization Coding and its Relationship to Vascular Access Procedures

1. Lower Extremity Revascularization Coding and itsRelationship to Vascular Access Procedures ASDIN Coding University

2. 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

3. 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

4. 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)

5. 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

6. 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.

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. LER Affects on Vascular Access Coding

21. 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)

22. 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

23. 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.