Endovascular Revascularization of the Lower Extremities

Today, “Spotlight on CPT” focuses on endovascular revascularization procedures for lower extremity arterial occlusive disease, an area that experienced significant restructuring in the 2026 CPT code set.

Peripheral arterial disease (PAD) occurs when plaque buildup causes narrowing (stenosis) or blockage (occlusion) of the arteries supplying blood to the lower extremities. Endovascular procedures such as angioplasty, stent placement, atherectomy, or intravascular lithotripsy are commonly performed to restore blood flow and relieve symptoms such as claudication or critical limb ischemia.

In the 2026 CPT update, the previous code range 37220–37235 was deleted and replaced with a new coding structure 37254–37299. These changes introduced a more comprehensive system for reporting lower extremity revascularization procedures and include 46 new codes designed to better capture the complexity of these interventions.

Vascular Territory Concept

A key concept in the new coding framework is the use of vascular territories. A vascular territory represents a group of anatomically related arteries. This structure simplifies coding by allowing coders to report a single primary intervention code per territory, with additional add-on codes when multiple vessels within that territory are treated.

The four vascular territories are:

• Iliac territory
• Femoral and popliteal territory
• Tibial and peroneal territory
• Inframalleolar territory

Each territory contains specific arteries and coding rules that determine how many primary and add-on codes may be reported.

Lesion Complexity

The new code structure also differentiates between straightforward and complex lesions.

• Straightforward lesions generally represent stenosis, where the vessel is narrowed but not completely blocked.
• Complex lesions typically represent occlusions, where the artery is completely blocked and may require more advanced intervention.

This distinction is important because the CPT codes specify whether the treatment was performed on a straightforward or complex lesion, which directly impacts code selection.

Procedures Included in the Codes

The CPT codes for lower extremity revascularization include all maneuvers necessary to complete the intervention. These bundled services include:

• Vascular access and catheterization
• Imaging guidance and radiological supervision
• Lesion crossing and device placement
• Embolic protection when used
• Vessel closure following the procedure

Because these services are included in the procedure codes, they are not reported separately.

Additional Coding Considerations

When multiple vessels within the same vascular territory are treated, add-on codes may be reported for each additional vessel with a distinct lesion. However, lesions that span multiple vessels and are treated with a single therapy are coded with one treatment code only.

If separate lesions occur in different vascular territories and require separate interventions, multiple primary codes may be reported—one for each affected territory.

Careful review of the procedural documentation and anatomical location of the treated vessels is essential when assigning codes within this new framework.

Final Thoughts

The new coding structure for lower extremity revascularization procedures represents a significant change for coding professionals. By organizing codes around vascular territories and lesion complexity, CPT 2026 provides a more accurate way to report these increasingly sophisticated endovascular procedures.

Understanding the territory-based coding system and the distinction between straightforward and complex lesions will be key for accurate reporting of these procedures.

Now, light has been shed on lower extremity endovascular revascularization in CPT 2026.

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.

Boari Bladder Flap

This edition of In the kNOW will be presenting information on a procedure highlighted in the April 2026 ICD-10-PCS updates—the Boari bladder flap. This surgical technique is used in the reconstruction of the ureter when a segment of the ureter has been damaged, removed, or is otherwise unable to function properly. Ureteral injuries may occur due to trauma, disease, or complications from prior surgical procedures. The Boari bladder flap is generally used when the ureteral segment requiring reconstruction is long or there is not enough mobility of the ureteral segment to perform a primary repair.

During a Boari bladder flap procedure, a portion of the bladder wall is surgically mobilized and shaped into a flap that can be extended upward to bridge the gap between the bladder and the remaining healthy portion of the ureter. This technique allows the surgeon to restore urinary flow from the kidney to the bladder without the need for more complex grafting procedures.

Source: https://operativereview.com/ureter-injury/

From a coding perspective, the April 2026 ICD-10-PCS update introduced a new table specifically designed to capture reconstruction of the ureter, which includes procedures such as the Boari bladder flap. The addition of this table allows coders to more accurately represent these reconstructive procedures that were previously more difficult to classify within existing PCS tables.

Notice that the new PCS table is in the Medical and Surgical section, in the urinary body system, and addresses a Transfer procedure. Coding professionals will recall that the root operation Transfer is defined as “moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part”, which is exactly what is being done with the Boari flap. A segment of bladder is peeled back and used to form the ureteral reconstruction. 

As procedural techniques continue to evolve, coding systems must adapt to ensure accurate representation of these surgical approaches. Being aware of new tables and code options related to reconstructive urologic procedures will help coding professionals correctly capture the services performed.

Now you are In the kNOW!!

 

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.

Endovascular Repair of the Thoracic Aorta

This edition of “Spotlight on CPT” focuses on endovascular repair of the thoracic aorta, an area that has seen important clarification and restructuring in the 2026 CPT code set.

Endovascular repair of the thoracic aorta involves the delivery, positioning, and deployment of an endograft to treat aneurysms or other pathologic conditions of the thoracic aorta. The thoracic aorta includes the ascending aorta, aortic arch, and descending thoracic aorta down to the origin of the celiac artery. In these procedures, terms such as endograft, stent graft, endovascular graft, and endoprosthesis all refer to a covered stent used to reinforce the vessel wall and restore normal blood flow.

Coding for thoracic aortic repair depends largely on the anatomic relationship of the graft placement to the left subclavian artery. The CPT codes describe whether the procedure involves coverage of the left subclavian artery, avoidance of that vessel, or use of a branched graft system designed to maintain perfusion to the artery.

The 2026 CPT code set includes the following codes for these procedures:

33880 – Endovascular repair of the thoracic aorta with deployment of an aorto-iliac tube endograft that covers the left subclavian artery, including associated extensions placed proximally in the arch or ascending aorta and distally to the celiac artery.

33881 – Endovascular repair of the thoracic aorta with deployment of an aorto-iliac tube endograft that does not cover the left subclavian artery, including extensions from the level of the left subclavian artery to the celiac artery.

33882 – Endovascular repair using a branched multipiece endograft system that includes a fenestration for the left subclavian artery with associated stent graft placement.

In some cases, additional procedures may be required following the initial repair. These delayed services have their own CPT codes.

33883 – Delayed placement of proximal extension prosthesis(es) after thoracic aortic repair that does not involve coverage of the left subclavian artery.

33886 – Delayed placement of distal extension prosthesis(es) from the level of the left subclavian artery to the celiac artery following endovascular repair of the descending thoracic aorta.

It is important to note that code 33884 has been deleted, further refining the reporting structure for these procedures.

As with many endovascular procedures, multiple notes precede these codes in the CPT manual. Coding professionals should carefully review these notes, as they define included services such as catheterization, imaging guidance, and radiologic supervision and interpretation, which are typically bundled into the primary procedure code.

Understanding the anatomy involved and whether the repair involves coverage, preservation, or reconstruction of the left subclavian artery is essential for correct code assignment.

Now, light has been shed on endovascular repair of the thoracic aorta in CPT 2026.

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.

Springtime Slip-Ups

by Dianna Foley, RHIA, CHPS, CCS, CDIP

Test your ICD-10-CM injury and external cause knowledge by coding the scenarios below.

Spring has arrived and the Klutz family is thrilled to be outdoors again after a long winter. Flowers are blooming, the weather is warming up, and the children are eager to enjoy all the activities that come with the season. Of course, as we’ve come to expect any outdoor activities that the Klutz children participate in are likely to end with at least a few mishaps. Let’s see what befalls them this spring.

Little Dana was helping her mother plant flowers in the backyard garden. While digging in the soil with a small hand shovel, she accidentally jabbed the shovel into her left palm causing a small puncture wound. Luckily, Mrs. Klutz had a first aid kit nearby and quickly cleaned and bandaged the wound.

Raymond was flying a kite at the park during a breezy spring afternoon. While running backward to get the kite airborne, he tripped over a tree root and fell, landing on his right knee. A bruise quickly developed, but after a few minutes of rest he was back to watching the kite soar.

Peter decided to climb the family’s apple tree in the back yard to see if any blossoms were forming. While reaching out on a branch for a better look, he slipped and fell from the tree, landing on his left wrist. After a visit to urgent care, it was confirmed that Peter had a sprained wrist.

Janine volunteered to mow the lawn for the first time that season. While pushing the mower across the yard, a small stone was kicked up from beneath the mower and struck her on the right shin, leaving a painful contusion.

Egon was determined to wash the family car as part of his spring chores. As he stepped on the wet driveway while rinsing the car, he slipped and fell, landing on his tailbone. Although sore, Egon was relieved to learn that nothing was broken.

Thankfully, none of the Klutz children suffered major injuries this spring—though their parents suspect it’s only a matter of time before the next adventure results in another visit to the clinic!

Click HERE for the answers.