Interventional Part

intraprocedural roadmapping and radiological supervision and 2
interpretation, including pressure gradient measurements, flush
aortogram and diagnostic renal angiography when performed; 0339T 5 N
unilateral 1 0. /A
Transcatheter renal sympathetic denervation, percutaneous 9 00
approach including arterial puncture, selective catheter 2
placement(s) renal artery(ies), fluoroscopy, contrast injection(s),
intraprocedural roadmapping and radiological supervision and
interpretation, including pressure gradient measurements, flush
aortogram and diagnostic renal angiography when performed;
bilateral

Catheter, transluminal angioplasty, drug-coated, non-laser C2623 N N/ N
/ A /A
A

♦ Inpatient-Only Procedure Add-on Code
# Restricted Coverage

CODING INSTRUCTIONS:
193. See the "Lower Extremity Endovascular Revascularization" section for coding
instructions specific to lower extremity angioplasty. The rules below are specific to
angioplasty performed other than in the lower extremities.
194. Codes 37246 and 37247 describe initial and additional vessel angioplasty procedures in
the aorta and the brachiocephalic (and branches), renal, and visceral arteries. There is
only one "initial" angioplasty per session. All other vessel angioplasties are considered
"additional" angioplasties. Do not submit code 37246 or 37248 more than once more
session.
195. Codes 37248 and 37249 describe initial and additional vessel venoplasty procedures.
196. Angioplasty and venoplasty codes include utilization of both percutaneous and open
approaches.
197. All percutaneous and open angioplasty codes are allowed as outpatients.
198. Do not use codes 37246-37249 for treatment of stenoses in the dialysis circuit when
accessed via the dialysis circuit. Use codes 36902, 36905, and 36907 as indicated for
angioplasty in the peripheral and central segments of a dialysis fistula in these locations.
(See the section on AV shunt intervention.) Codes 37246-37249 may be used for vessel

treatment outside of the dialysis circuit (e.g., 37246 for treatment of a proximal 90%
subclavian artery stenosis in a patient with a forearm shunt) or when the approach is
not via a dialysis circuit access and is in the central segment. In the case of a remote
access, report the catheter placement code (e.g., 36012 from a femoral approach) as
well as 37248 for the central venoplasty.
199. Hospitals should submit device code C2623 for each drug-eluting balloon (DEB) used
during a femoral/popliteal revascularization procedure. Reimbursement for code C2623
expires 12/31/2017. CMS (in the final rule) has decided to collect data for use of the DEB
(C2623) and femoral/popliteal angioplasty (37224) in 2018, without reimbursement.
Follow ZHealth Publishing for updates regarding drug-eluting balloons.
200. Selective catheter placement codes (e.g., 36245) are submitted in addition to the
non-neuro, non-lower extremity angioplasty codes.
201. If diagnostic bilateral selective renal angiography (36252) is followed by renal
angioplasty or stent placement, the catheter placement is bundled.
202. If renal angioplasty or stent placement of a known lesion is performed (without
diagnostic angiography at the same session), the catheter placement for angioplasty is
separately coded.
203. Diagnostic angiography prior to angioplasty may be coded separately; however, it
should not be coded if the imaging was merely to reconfirm a known lesion, to size the
vessel, to guide the catheter to the lesion, to confirm final catheter placement, or to
comment on the results of the angioplasty. True diagnostic angiography requires a -59
modifier at the time of intervention.
204. Do not code angioplasty to treat a segment of the same vessel that has been treated
by a stent. If an atherectomy is performed, followed by an angioplasty, both the
angioplasty and the atherectomy (0234T-0238T) are coded when both are performed in
suprainguinal arteries. Atherectomy in the infrainguinal arteries bundles angioplasty in
the same vessel.
205. Do code angioplasty to treat a complication of a stent placement when the
complication is in a separate vessel (e.g., dissection into a separate vessel, or displaced
plaque obstructing a separate and distinct vessel above or below the stent deployment
zone). If the angioplasty is in the same named vessel as the stent, it is bundled.
206. Angioplasty is coded per vessel treated, not per lesion treated. A vessel is usually
defined as an additional level of catheter placement selectivity.
207. The venous angioplasty codes apply to all venous structures including portal and
mesenteric venous structures; however, they do not apply to venoplasty within the
peripheral and central segments of an AV dialysis graft when the approach is via the
dialysis circuit directly. Use code 36902 or 36905 for venoplasty or arterial angioplasty
within the peripheral segment of an upper extremity AV dialysis graft. Code 37246 may
be used on the same patient for multiple procedures in the same extremity, but only if
the arterial intervention is in a native extremity artery separate from the arterial
anastomosis/peri-anastomotic region. If both an upper extremity arterial anastomosis

and an upper venous extremity lesion are treated in a patient with an AV fistula/shunt,
only submit code 36902 or 36905. Separate central venoplasty can be additionally
reported with add-on code 36907 when performed via the dialysis circuit. Central
venoplasty from an access separate from the dialysis circuit is reported separately with
code 37248 (37238 for stent placement) (e.g., from a common femoral vein approach).
208. Separate cardiac codes exist for pulmonary artery angioplasty (92997, 92998). Use
established arterial vascular stent placement codes 37236/37237 for pulmonary artery
stent placement(s). These procedures include catheter placements at the time of
cardiac catheterization.
209. Use codes 37248/37249 for venoplasty of pulmonary vein stenoses and codes
37238/37239 for stent placement across pulmonary vein stenoses. Catheter placement
codes are bundled in the pulmonary veins.
210. Coronary intervention rules are similar to the lower extremity endovascular
revascularization codes 37220-37235; however, there remain some significant
differences. See our Diagnostic & Interventional Cardiovascular Coding Reference for
further details of codes 92920-92944 and C9600-C9608.
211. Infrainguinal arterial revascularization guidelines have defined hierarchy as follows:
stent with atherectomy supersedes atherectomy, which supersedes stent placement,
which supersedes angioplasty.
212. Vertebral and carotid artery angioplasty are considered experimental and are
non-covered services for Medicare. Use code 37246 to report carotid or vertebral
angioplasty without stent placement. Add a -GZ modifier to indicate this procedure is
non-covered. Since February 5, 2007, CMS (per NCD 20.7) has implemented coverage
for intracranial angioplasty and stent placement when cerebral artery stenosis is > 50%
in patients with intracranial atherosclerotic disease when furnished in accordance with
FDA-approved protocols governing Category B IDE clinical trials. These are
inpatient-only procedures for hospitals. Physicians report codes 61630 and 61635.
These codes have restricted coverage and are priced by the Medicare Contractor for
physician reimbursement. Hospitals use code 37799 (per the Medicare Claims
Processing Manual) when stenting is performed in accordance with these FDA protocols.
213. Do not report angioplasty or venoplasty codes 37246-37249 when angioplasty is
performed at the same session in the same vessel as a stent placement (e.g., do not
submit separate angioplasty with codes 36903, 36906, 36908, 37215-37218,
37220-37235, 61635, 92920-92944, 0075T, 0076T, or C9600-C9608).
214. Report code 37246 for carotid or vertebral angioplasty without stent placement. Since
this is a non-covered service for Medicare patients, consider adding a -GZ modifier to
identify as such.
215. Use brachiocephalic angioplasty code 37246 for angioplasty of the left subclavian
artery. This is also appropriate for the right brachiocephalic and subclavian arteries, as
well as any distal upper extremity vessels, including the axillary, brachial, radial, and
ulnar arteries bilaterally. Codes 37246 and 37247 are also used for angioplasty

treatment of stenoses of the visceral and renal arteries, as well as the aorta. Use code
36902 or 36905 for angioplasty at the arterial anastomosis of an upper extremity AV
graft or fistula.
216. Effective 8/2012, the Wingspan intracranial stent is approved for patients 22-80 years
old who meet the following criteria: 1) patient has had two or more strokes despite
aggressive medical therapy, 2) patient's most recent stroke occurred more than seven
days ago, 3) strokes are related to intracranial arterial stenosis of 70-99%, and 4) patient
has made a good recovery from previous stroke and has a modifier Rankin score of
three or less. The patient must not be treated with intracranial stent therapy if he/she
has had onset of stroke symptoms within the last seven days. This treatment is not for
the treatment of transient ischemic attacks (TIAs). Please follow Medicare Claims
Processing Manual guidance for billing purposes.
217. Angioplasty of renal and visceral vessels and their branches are covered procedures
and can be billed to Medicare. LCDs need to be reviewed, as renal and visceral stent
coverage is at local payer discretion. Documentation of exact percentage stenosis prior
to intervention is recommended. Discussion with your payer may be necessary.
218. LCDs from your payer may limit indications and coverage of some less commonly
performed angioplasties and stent placements. Be sure to review all LCDs that your
payer has published prior to coding these complex procedures. This is also important
when coding dialysis intervention.
219. Kissing balloon angioplasty should be coded as only one angioplasty and two catheter
placements when the second balloon is inflated to prevent plaque movement. If there
are associated stenoses in both vessels ballooned, then code for two angioplasties.
220. Do not code for roadmapping, guiding shots, or other contrast injection during
angioplasty.
221. Do not code for follow-up angiography post angioplasty, as it is included in the
angioplasty code.
222. Exception: If there is a clinical change in symptoms post intervention away from the
site of intervention (e.g., development of a cold foot once renal angioplasty is complete)
then diagnostic angiography coding may be considered, as it is now medically necessary.
The clinical change must be outside the target area of intervention to submit this
additional imaging code.
223. Do not code angioplasty if done to "pre-dilate" a lesion for subsequent stent
placement.
224. Do not code angioplasty if the balloon size is too small to give a good result (e.g., 3 mm
balloon in an 8 mm artery gave "suboptimal" result, requiring an 8 mm stent. All
angioplasties are bundled in the same vessel as stent placement.
225. Do not code angioplasty to deploy a stent.
226. Do not code angioplasty to further dilate or completely deploy a newly placed stent at
the same session.

227. Do not code angioplasty if intent of procedure was to place a stent.
228. Do not code angioplasty if angioplasty results in "no residual stenosis", but because

this "lesion is prone to restenosis, a stent was placed anyway". Only code for the stent
placement.
229. Do not code angioplasty for any balloon angioplasty in the treatment zone of an aortic
(EVAR, TEVAR), fenestrated aortic (FEVAR), or iliac stent graft placement.
230. Do not use vascular angioplasty codes for balloon dilation of non-vascular structures
(e.g., biliary, urinary, gastrointestinal).
231. Do not code angioplasty at the same location as an extracranial vertebral, cervical
carotid, intrathoracic common carotid, or intracerebral stent placement. In these cases,
the angioplasty is bundled with stent placement codes 0075T, 0076T, 37215, 37216,
37217, 37218, and 61635. This applies to all vessels that a stent is also placed
(angioplasty is bundled).
232. Carotid and vertebral artery angioplasty remain non-covered services for Medicare in
2018.
233. Do not code for two angioplasties when a short "bridging" lesion between two vessels
is treated. This is considered one angioplasty when short, contiguous stenoses are
present. Documentation is critical to accurate coding of these interventions.
234. Cutting balloon angioplasty is coded the same as POBA (plain old balloon angioplasty).
235. Lithoplasty (angioplasty with a catheter that also disrupts vessel wall calcification) is
coded the same as POBA.
236. Add a -59 modifier to true diagnostic angiography performed at the same setting as a
peripheral intervention, such as angioplasty.
237. Code for two angioplasties performed in adjacent vessels when separate and distinct
non-bridging stenoses are present.
238. Code for two angioplasties when performed in adjacent vessels if the entire length of
both vessels is treated (even if a bridging lesion) due to the extensive nature of
treatment, unless this is treated with a single long balloon device. This applies to both
arterial and venous occlusions and stenoses.
239. Do not report two initial arterial angioplasty codes (37246), as the second angioplasty
is of an additional artery (37247).
240. Do not report two initial venoplasty codes (37248), as the second venoplasty is of an
additional vein (37249).
241. Do not use coronary angioplasty codes for peripheral angioplasties performed in the
cardiac catheterization laboratory.
242. Do not use drug-eluting coronary stent codes C9600-C9608 when a drug-eluting stent
is placed in a non-coronary vessel. This would be coded the same as a bare metal stent
placed in the same non-coronary vessel (e.g., 37236, 37215, 0075T, etc.).

243. Angioplasty/venoplasty codes (37246-37249) and lower extremity revascularization
angioplasty codes (e.g., 37220, 37222, 37224, 37228, 37232) are appropriate when the
angioplasty is performed by percutaneous or open approach.

244. Cryoplasty is considered by CMS to be a PTA. To avoid confusion, it should be
documented by the physician as a balloon angioplasty utilizing a Polar cath balloon. The
lower extremity and coronary revascularization codes allow use of cryoplasty and
cutting balloons as angioplasty balloons (per CPT code description). Similarly, lithoplasty
utilizes an angioplasty device that also disrupts arterial wall calcification to facilitate
better results in patients with calcified stenoses.

245. Only code for the stent placement when angioplasty is also performed at the same site
even if the intent of the angioplasty was to fully treat the stenosis or occlusion, but
because of significant residual stenosis, flow-limiting dissection, acute occlusion, or
significant residual gradient, a stent placement was required for successful outcome.
This includes carotid, cerebral, vertebral, coronary, lower extremity, all other arteries,
and all veins. All angioplasties are bundled with stent placement at the same site or in
the same vessel.

246. Only code one angioplasty when performed in a bypass graft, even if both the proximal
and distal anastomoses are treated for separate high grade stenoses with angioplasty
technique. The entire graft is considered one vessel for coding purposes. If an
angioplasty is performed at one site in a graft and a stent is placed at the same site or a
separate site in the same graft, only submit a code for a single stent placement (and not
for an angioplasty).

247. One approach to treatment of renovascular hypertension involves catheter-directed
radiofrequency ablation (or alcohol ablation) of sympathetic renal nerves (renal artery
sympathectomy). This does not utilize angioplasty or stent placement. This is performed
using transcatheter technique with selection of the proximal renal arteries utilizing a
new device (e.g., Symplicity catheter system). Codes 0338T and 0339T describe
unilateral or bilateral treatment respectively. These codes include catheter placements,
imaging, pressure measurements, and renal denervation.

EXAMPLE(S):

1) Hypertensive patient undergoes abdominal aortogram with selective renal angiography of
two left renal arteries and one right renal artery (36252-59). Severe stenoses of both left renal
arteries are balloon dilated using percutaneous access (37246, 37247).

2) Patient with splenomegaly and esophageal varices. Transjugular approach to the hepatic vein
(36011), followed by puncture into the portal vein (36481) and advancement of the catheter
into the portal system with splenoportography and pressures (75885-59). This shows separate
splenic vein stenosis and portal vein occlusion related to previous pancreatitis. Varices and a
trans-stenotic gradient are present. Balloon venoplasty (36011-59, 37248) shows resolution of
the stenosis in the splenic vein. A preliminary 4 mm venoplasty (not coded) followed by 10 mm
self-deployed stent placement (37238) in the portal vein occlusion (a separate vessel) results in a

widely patent vessel.
Note: This is not a transjugular intrahepatic portosystemic shunt (TIPS) procedure.
3) Patient with TIPS stenosis seen on ultrasound. Via a transjugular route, a catheter is
advanced through the hepatic vein, TIPS shunt, and into the portal vein. Venogram and
pressures show a severe stenosis, which is treated successfully with balloon venoplasty (37183).
Note: Code 37183 is an all-inclusive code for TIPS revision and is status indicator is T, which
allows payment as an outpatient.

Atherectomy, Suprainguinal

7 Vascular Interventional Coding
Atherectomy, Suprainguinal Pages: 275-278

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
Atherectomy is a debulking procedure used to remove atherosclerotic plaque. It may be
followed by adjunctive angioplasty or stent placement. It can be a stand-alone procedure or can
be utilized to "clean-up" a post angioplasty complication such as a dissection. There are three
primary types of atherectomy devices:

Side-cutting device - This device may or may not employ a balloon to position the side
cutter against a plaque. (Simpson AtheroCath, SilverHawk, TurboHawk, Pantheris)

Rotational device - This device spins at a high rate of speed to cut through plaque and
"widen" a channel. It can be used in calcified lesions, while the side-cutting device is
best in treating eccentric lesions. (Rotablator, Diamondback 360® Orbital Atherectomy
System, Pathway Jetstream G3®, Phoenix® Atherectomy System)

Photoablation device (called a laser) - This is an FDA-approved device for use in infrainguinal
vessels and has been removed from the non-covered sections of LCDs. It may be used as
a preliminary recanalization device or as a definitive procedure device in smaller vessels.
Large devices may become available for definitive procedure performance in vessels as
large as 5-6 mm. (Excimer)

Pulverization device - High velocity jets of saline can disrupt and pulverize plaque, sending
tiny particles through the distal vessels, passing safely through the capillaries (Crosser
CTO Recanalization Catheter High Frequency Mechanical Recanalization System,
FDA-approved as an atherectomy device).

A code set in the Category III section of the CPT Codebook (0234T-0238T) is utilized for
atherectomy in the suprainguinal vessels.

CLINICAL INDICATIONS:
Complete occlusions for recanalization, definitive treatment of small vessel stenosis,
eccentric plaque treatment, debulking procedures, and treatment of complications (e.g.,
dissection).

CODES:

TT
O PRO O
INITIAL A T CEA A T
PROCEDURE DESCRIPTION (OPEN OR PERCUTANEOUS) PROC P AL CH P AL
CODE C R AD C R
V D'L V
UU

Transluminal peripheral atherectomy, open or 0234T 5 023 5
percutaneous, including radiological supervision and 1 0. 4T 1 0.
interpretation; renal artery 9 00 9 00
3 3

Transluminal peripheral atherectomy, open or ♦ 0235T N 0. ♦ N 0.
percutaneous, including radiological supervision and / 00 023 / 00
interpretation; visceral artery (except renal), each vessel A 5T A

Transluminal peripheral atherectomy, open or 0236T 5 N/A
percutaneous, including radiological supervision and 1 0.
interpretation; abdominal aorta 9 00
3

Transluminal peripheral atherectomy, open or 0237T 5 023 5
percutaneous, including radiological supervision and 0238T 1 0. 7T 1 0.
interpretation; brachiocephalic trunk and branches, each 9 00 9 00
vessel 3 3
Transluminal peripheral atherectomy, open or
percutaneous, including radiological supervision and 5 0. 023 5 0.
1 1

interpretation; iliac artery, each vessel 9 00 8T 9 00
♦ Inpatient-Only Procedure 44

CODING INSTRUCTIONS:
248. See the "Lower Extremity Endovascular Revascularization" section for coding
instructions specific for infrainguinal lower extremity atherectomy. The rules below are
specific to atherectomy performed other than in the infrainguinal lower extremities.
249. Code separately for catheter placement. However, if atherectomy in the iliac is
followed by iliac angioplasty or stent placement in the same vessel (37220-37223), the
catheter placement is bundled due to the guidelines for codes 37220-37223.
250. Code for angioplasty or stent placement (if performed) in the same vessel or at the
same site in addition to atherectomy in suprainguinal arteries.
251. Code for closure device placement (G0269) when done. Do not code for angiography
related to closure device placement. This imaging is bundled.
252. Code separately for diagnostic angiography prior to procedure if there are no prior
studies. Diagnostic angiography at the time of atherectomy requires a -59 modifier.
253. Coronary intervention rules dictate that if an angioplasty, atherectomy, and stent
procedure are done in the same coronary artery or branch, only the highest level of
intervention can be coded. These guidelines also apply to the infrainguinal lower
extremity revascularization procedures with the highest level of intervention: stent with
atherectomy, which supersedes atherectomy, which supersedes stent placement, which
supersedes angioplasty alone. This is not the case with the Category III atherectomy
codes 0234T-0238T. Atherectomy of arteries described by codes 0234T-0238T are coded
in addition to any angioplasty or stent in the same vessel or site.
254. Atherectomy codes are based on the vessel treated.
255. Atherectomy is the removal of atheroma; thrombectomy is the removal of thrombus.
256. Atherectomy is coded per vessel treated, not per stenosis.
257. There are no codes for atherectomy in the venous system. Use unlisted vascular code
37799 for removal of stenosis (usually intimal hyperplasia) from the venous side of an
AV graft using an atherectomy device. The Diamondback Orbital atherectomy device is
FDA-approved for use in AV grafts. If performed at the arterial anastomosis of an AV
graft or fistula, use the appropriate atherectomy code 0237T, 0238T, or 37225
depending on the artery involved.
258. Do not code for laser atherectomy in visceral vessels, as the procedure is currently only
FDA-approved for use in infrainguinal and coronary arteries.
259. Do not code for follow-up imaging (75898) or for follow-up diagnostic angiography
(e.g., 75710) post atherectomy. Atherectomy codes include all imaging related to

performing the procedure (the S&I is bundled). Diagnostic imaging is separately
reported.
260. Do not code for two atherectomies when a short "bridging" lesion between two
vessels is treated. This is considered one atherectomy when contiguous stenoses are
treated.
261. Code for two atherectomies when performed in adjacent vessels for separate and
distinct stenoses. Physician documentation must clearly delineate the separate
stenoses.
262. Code for two atherectomies when performed in adjacent vessels if the entire length of
both vessels is treated (even if a bridging lesion) due to the extensive nature of
treatment.
263. Do not code cutting balloon angioplasty with atherectomy codes. This angioplasty is
coded the same as a plain old balloon angioplasty (POBA) procedure.
264. Do not code for coronary atherectomy (92924) when a subsequent stent is placed in
the native coronary artery vascular distribution. Code 92933 describes stent with
atherectomy of a native coronary artery or branch. Code C9602 describes drug-eluting
stent with atherectomy of a native coronary artery or branch.
265. Do not code coronary atherectomy when atherectomy is performed in a visceral
artery.
266. Code for both atherectomy and stent placement performed at the same site if the
intent of the atherectomy was to fully treat the stenosis or occlusion, but because of
significant residual stenosis, flow-limiting dissection, acute occlusion, or significant
residual gradient, a stent placement was required for successful outcome. This does not
apply to infrainguinal lower extremity vessels (or coronary arteries) where combination
codes exist.
267. Do not code thrombectomy and atherectomy in the same vessel, as associated
thrombus in a stenotic vessel will be removed by the atherectomy device. Only code the
atherectomy. If there is a distal embolus, which is retrieved with an aspiration catheter
or thrombectomy device, do report code 37186 for secondary thrombectomy.
268. If atherectomy/thrombectomy of a single vessel is performed with a single device with
"blades up and blades down", only code the atherectomy. The thrombus is considered
integral to the atheromatous lesion in the treated vessel. Thrombectomy is not billable
in the same vessel treated with atherectomy when treated with the same device.
269. Code for both angioplasty and atherectomy at the same site or in the same vessel
when performed to treat the lesion(s). Stent placement bundles angioplasty;
atherectomy does not (except in the coronaries and lower extremity arteries where the
angioplasty is bundled).

EXAMPLE(S):

1) Via transfemoral technique, a known 90% proximal right renal artery stenosis is treated with
an atherectomy device (0234T, 36245). Follow-up imaging (bundled) shows occlusion of a third
order upper pole branch of the posterior division. A catheter is advanced (add 36247, delete
36245), and suction thrombectomy (37186) is performed. Imaging (bundled) shows restoration
of patency; however, a residual 40% stenosis is present in the proximal renal artery. A 6 mm
drug-eluting stent is placed (37236). Angiogram through the femoral sheath shows a 6 mm
common femoral artery (imaging bundled with the closure device placement). A "Boomerang"
device is placed at the puncture site (bundled with 37236).

2) Patient with left leg claudication. Via right femoral approach, a catheter is placed in the distal
aorta with bilateral lower extremity angiography performed, demonstrating calcified 90% left
proximal common iliac and 80% diffuse left external iliac artery stenoses (75716-59). These are
separate and distinct stenoses with a normal segment in the mid to distal left common iliac
artery. Atherectomy with a Jetstream G3 ® device is performed in both vessels (36246, 0238T,
0238T-59). Suboptimal result in the external iliac artery requires drug-eluting stent placement
(add 37221, delete 36246). Closure device is placed (bundled with 37221).

3) Patient with poorly functioning right arm AV graft. Percutaneous access is obtained, followed
by 6 French sheath placement and complete imaging (36901). A 90% venous anastomotic
stenosis is seen and treated with a Diamondback Orbital atherectomy device (37799). Due to
50% residual, an angioplasty with a 6 mm high pressure balloon is performed (add 36902,
delete 36901) with excellent result. A second 80% lesion in the cephalic vein is angioplastied (no
code); however, this vessel ruptures, requiring stent placement (add 36903, delete 36902). A
second stent is placed in the subclavian vein (via the dialysis circuit access) at a site of an
occlusion (36908).

Note: If the subclavian vein stenosis had been treated with a stent via a common femoral vein
access, codes 36012 and 37238 would be used instead of 36908.

7 Vascular Interventional Coding

Vascular Stent Placement, Non-Lower Extremity Pages:
279-287

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
Stent placements can be performed in arteries, veins, AV grafts, TIPS shunts, bile ducts, bronchi,
the esophagus, and the bowel. Stent placement procedures involving vascular structures
(excluding coronary, vertebral, carotid, or intracerebral vessels) are coded the same based on

whether the vessel is an artery or a vein. This may be a "primary" procedure with the initial
intent of the physician to place a stent, or may be a secondary or "rescue" procedure after
failed angioplasty or atherectomy. In the case of a failed angioplasty, only the stent is coded.
With atherectomy, both the stent placement and the atherectomy are coded (other than
coronary and lower extremity revascularizations, which bundle these into a single code). An
initial diagnostic angiogram is often performed; catheters are selectively placed followed by
stent deployment. Some stents are balloon-expandable while others are self-expanding. Nearly
all stents need some balloon assistance to fully deploy the stent. Stents can be very accurately
deployed and vary in diameter, length, and construction. Several stents may be needed to
cover multiple blockages in one vessel. Some stents have coatings (such as heparin) while
others are drug-eluting, releasing drugs such as Taxol over an extended period of time to
prevent restenosis. Biodegradable stents are also available. The coding is unchanged if used to
treat stenotic or occlusive disease. The use of covered stents or stent grafts requires unique
CPT codes when used for treatment of aortic or iliac aneurysmal disease.

CLINICAL INDICATIONS:
In most cases, stent placement is the primary intervention for stenotic or occlusive disease.
Stent placement may also be utilized to remedy an abrupt occlusion, tack down a
flow-limiting dissection, or improve a significant elastic recoil or residual stenosis from a prior
unsuccessful angioplasty or atherectomy. Stents may be used to treat ruptures of veins (as
occurs occasionally with dialysis venous shunt venoplasty). Covered stents can be used for
similar complications in the arterial system.

CODES: PROC CODE T S
PROCEDURE DESCRIPTION 37236 O &I
Transcatheter placement of an intravascular stent(s) (except A TA C
lower extremity artery(s) for occlusive disease, cervical carotid, PL O
extracranial vertebral or intrathoracic carotid, intracranial, or CR D
coronary), open or percutaneous, including radiological V E
supervision and interpretation and including all angioplasty U
within the same vessel, when performed; initial artery
5 13 B
1 .0 u
9 0 n
3 dl
e
d

Transcatheter placement of an intravascular stent(s) (except N 6. B
lower extremity artery(s) for occlusive disease, cervical carotid, / 22 u
extracranial vertebral or intrathoracic carotid, intracranial, or A n
coronary), open or percutaneous, including radiological dl
supervision and interpretation and including all angioplasty 37237 e
within the same vessel, when performed; each additional artery d
(List separately in addition to code for primary procedure)

Transcatheter placement of an intravascular stent(s), open or 37238 5 B
percutaneous, including radiological supervision and 1 8. u
interpretation and including angioplasty within the same vessel, 9 73 n
when performed; initial vein 3 dl
e
d

Transcatheter placement of an intravascular stent(s), open or N 4. B
percutaneous, including radiological supervision and / 43 u
interpretation and including angioplasty within the same vessel, A n
when performed; each additional vein (List separately in addition dl
to code for primary procedure) 37239 e
d

Introduction of needle(s) and/or catheter(s), dialysis circuit, with 36903 5 B
diagnostic angiography of the dialysis circuit, including all direct 1 9. u
puncture(s) and catheter placement(s), injection(s) of contrast, 9 24 n
all necessary imaging from the arterial anastomosis and adjacent 3 dl
artery through entire venous outflow including the inferior or e
superior vena cava, fluoroscopic guidance, radiological d
supervision and interpretation and image documentation and
report; with transcatheter placement of intravascular stent(s),
peripheral dialysis segment, including all imaging and
radiological supervision and interpretation necessary to perform
the stenting, and all angioplasty within the peripheral dialysis
segment

Percutaneous transluminal mechanical thrombectomy and/or 36906 5 14 B
infusion for thrombolysis, dialysis circuit, any method, including 1 .9 u
all imaging and radiological supervision and interpretation, 9 5 n
diagnostic angiography, fluoroscopic guidance, catheter 4 dl
placement(s), and intraprocedural pharmacological thrombolytic e
injection(s); with transcatheter placement of intravascular d
stent(s), peripheral dialysis segment, including all imaging and
radiological supervision and interpretation necessary to perform
the stenting, and all angioplasty within the peripheral dialysis

circuit

Transcatheter placement of intravascular stent(s), central N 6. B
dialysis segment, performed through dialysis circuit, including all / 10 u
imaging and radiological supervision and interpretation required A n
to perform the stenting, and all angioplasty in the central dialysis dl
segment (List separately in addition to code for primary 36908 e
procedure) d

Transcatheter placement of intravascular stent(s), cervical ♦ 37215 N 29 B
carotid artery, open or percutaneous, including angioplasty, / .1 u
when performed, and radiological supervision and A8 n
interpretation; with distal embolic protection dl
e
d

Transcatheter placement of intravascular stent(s), cervical 37216 N 29 B
carotid artery, open or percutaneous, including angioplasty, / .3 u
when performed, and radiological supervision and A1 n
interpretation; without distal embolic protection dl
e
d

Transcatheter placement of intravascular stent(s), intrathoracic ♦ 37217 N 31 B
common carotid artery or innominate artery by retrograde / .5 u
treatment, open ipsilateral cervical carotid artery exposure, A3 n
including angioplasty, when performed, and radiological dl
supervision and interpretation e
d

Transcatheter placement of intravascular stent(s), intrathoracic ♦ 37218 N 23 B
common carotid artery or innominate artery, open or / .6 u
percutaneous antegrade approach, including angioplasty, when A3 n
performed, and radiological supervision and interpretation dl
e
d

Transcatheter placement of extracranial vertebral artery ♦ 0075T N 0. B
stent(s), including radiologic supervision and interpretation, / 00 u
open or percutaneous; initial vessel A n
dl
e
d

Transcatheter placement of extracranial vertebral artery N 0. B
stent(s), including radiologic supervision and interpretation, / 00 u
open or percutaneous; each additional vessel (List separately in A n
addition to code for primary procedure) dl
♦ 0076T e
d

Transcatheter placement of intravascular stent(s), intracranial #♦ 61635 N 42 B
(eg, atherosclerotic stenosis), including balloon angioplasty, if / .4 u
performed A2 n
dl
e
d

Endovascular repair of iliac artery by deployment of an ilio-iliac ♦ 34707 N 33 B
tube endograft including pre-procedure sizing and device / .3 u
selection, all nonselective catheterization(s), all associated A1 n
radiological supervision and interpretation, and all endograft dl
extension(s) proximally to the aortic bifurcation and distally to e
the iliac bifurcation, and treatment zone angioplasty/stenting, d
when performed, unilateral; for other than rupture (eg, for
aneurysm, pseudoaneurysm, dissection, arteriovenous
malformation)

Endovascular repair of iliac artery by deployment of an ilio-iliac ♦ 34708 N 53 B
tube endograft including pre-procedure sizing and device / .6 u
selection, all nonselective catheterization(s), all associated A1 n
radiological supervision and interpretation, and all endograft dl
extension(s) proximally to the aortic bifurcation and distally to e
the iliac bifurcation, and treatment zone angioplasty/stenting, d
when performed, unilateral; for rupture including temporary
aortic and/or iliac balloon occlusion, when performed (eg, for
aneurysm, pseudoaneurysm, dissection, arteriovenous
malformation, traumatic disruption)

Endovascular repair of iliac artery bifurcation (eg, aneurysm, ♦ 0254T N 0. B
pseudoaneurysm, arteriovenous malformation, trauma, / 00 u
dissection) using bifurcated endograft from the common iliac A n
artery into both the external and internal iliac artery, including dl
all selective and/or nonselective catheterization(s) required for e
device placement and all associated radiological supervision and d
interpretation, unilateral

♦ Inpatient-Only Procedure Add-on Code
# Restricted Coverage

CODING INSTRUCTIONS:
Peripheral and Visceral Arterial and Venous Stent Placement Guidelines

270. See the "Lower Extremity Endovascular Revascularization" section for coding
instructions specific to lower extremity stent placement. Coronary stent procedures are
described in Dr. Z's Medical Coding Series: Diagnostic & Interventional Cardiovascular
Coding Reference. The rules below are specific to stent placement other than in the
lower extremities.

271. Stent placement procedural codes are specific to the vessel type treated (e.g., different
codes apply to stents placed in veins vs. arteries). There are no S&I codes for stent
placements. Coronary, carotid, vertebral, intracranial, and lower extremity stenting
procedures have separate series of codes used to describe these procedures. These
code sets also bundle the S&I codes.

272. Codes 37236 and 37238 are used for an initial stent placement in the artery or vein
respectively. They should not be used more than once per session regardless of the
number of vascular access sites.

273. Codes 37237 and 37239 are add-on codes and do not require modifiers to charge
additional units of service. Specifically, code 37237 is an add-on code to 37236, and
code 37239 is an add-on code to 37238.

274. Code per vessel stented, not per stent placed. Each vessel treated requires significantly
stenosed separate and distinct lesions; however, an exception exists (see instruction
#6).

275. A single long stent placement that traverses separate and distinct lesions in two
separate and distinct vessels should be coded as one stent placement. If two
overlapping stents are placed to treat these lesions, submit two stent placement codes.

276. A stent that traverses continuous or bridging stenoses across two vessels should be
coded as one stent placement. Per the SIR, use the stent code for the most selective
vessel in which that stent is placed (e.g., the most distal vessel from the aorta).

277. Code for any percutaneous thrombectomy (37184-37188, 36904) performed prior to
or after stent placement.

278. Code for any catheter-directed continuous infusion thrombolysis (see codes
37211-37214) prior to or following stent placement in the non-coronary arteries or
veins.

279. Code separately for selective catheter placement when using codes 37236-37239. Iliac
stent grafts, EVAR, and FEVAR procedures bundle certain catheter placements.

280. Do not code separately for selective catheter placement when using codes 37215,
37216, 37217, 37218, 0075T, 0076T, 0254T, 61635, and 34841-34848, as these codes
bundle the catheter placement related to the procedure. Non-selective catheter
placements are bundled with codes 34701-34712, while selective catheter placements
are reported with codes 34701-34712.

281. Codes 37215, 37216, 37218, 0075T, 0076T, and 37220-37239 describe procedures
performed by either percutaneous or open approach.

282. Code for the type of lesion treated, (occlusive disease vs. aneurysmal disease), not the
type of stent used (covered vs. coated vs. non-covered). If a stent is used as the sole
treatment of a non-aortic, non-iliac artery aneurysm, or pseudoaneurysm, use code
37236 to describe the arterial stent placement. Do not code as an embolization.

283. Use code 37236 when a stent or stent graft is placed in the lower extremity for
treatment of aneurysm ("non-occlusive" disease). The catheter placement is separately
billable in this case.

284. If both a stenosis (occlusive disease) and an aneurysm (non-occlusive disease) are
treated with stents in a single vessel, only submit a code for the primary indicated
procedure (e.g., only one stent in the femoral/popliteal territory can be submitted,
either code 37226 for stenosis or 37236 for aneurysm).

285. Do not code for angiography used to measure the vessel for stent or balloon size or for
follow-up after stent deployment. This is included in the stent placement code and is
considered part of guidance. Angiography of the ipsilateral cervical and cerebral vessels
is also bundled with stent codes 37215-37218, 0075T, 0076T, and 61635. Angiography
of the aorta and its branches is bundled with all EVAR, TEVAR, and FEVAR procedures as
well.

286. Codes 34707 and 34708 require use of an ilio-iliac endograft (stent graft). Do not use
these codes when an iliac aneurysm is treated with a "regular" stent.

287. Do not code angioplasty if it was used to predilate a stenosis for subsequent stent
placement.

288. Do not code angioplasty to fully dilate or post-dilate a stent.
289. Do not code angioplasty to fully dilate a "residual stenosis" in a self-deploying stent.

This is considered part of the complete stent deployment.
290. Do not code angioplasty at the site of stent placement (for any reason) when using

codes 37215, 37216, 37217, 37218, 0075T, 0076T, and 61635. All endovascular
revascularization and stent placement codes 37220-37239 include angioplasty if done.
Angioplasty in the stent graft deployment zone (e.g., stent graft placed for treatment of
aneurysm) is also bundled.
291. Do not report angioplasty or venoplasty codes 37246-37249 when angioplasty is
performed at the same session in the same vessel as a stent placement (e.g., do not

submit separate angioplasty with codes 36903, 36906, 36908, 37215-37218,
37220-37235, 61635, 92920-92944, 0075T, 0076T, or C9600-C9608).
292. Do not use code 37236-37239 for coronary, carotid, vertebral, intracranial arterial
artery, or lower extremity arterial stenting, as the CPT descriptors specifically exclude
the use of these codes in these vessels.
293. Code for both atherectomy and stent placement when (in the suprainguinal arteries)
the intent was to be successful with this initial therapy, but due to development of flow
limiting dissection, acute occlusion, 20-30% or greater residual stenosis, or 5 mm or
greater residual gradient, a stent placement became necessary.
294. Do not code for angioplasty (37246-37249) and stent placement (37236-37239), as
angioplasty is bundled when performed at the same lesion or in the same vessel treated
by stent placement.
295. If an angioplasty is performed and successful in opening up a stenotic vessel, and a
stent is placed anyways due to "risk of recurrence", only code the stent placement. You
can't code for preliminary angioplasty when a stent is subsequently placed.
296. Stent placement must meet medical necessity of a "hemodynamically significant"
stenosis to support submission of a stent placement code when done for treatment of
blockage. Documentation of percent diameter stenosis is recommended to support
subsequent intervention.
297. Do not submit a code for placement of nitinol "tacks" during angioplasty. Only submit
the angioplasty code. Do code for placement of endoanchors, screws, or tacks during
EVAR cases with code 34712.
Neurointerventional Stent Placement Guidelines
20. Use code 37215 or 37216 for carotid bifurcation stent placement depending on the use
of embolic protection device (EPD). Code 37215 includes use of embolic protection,
while code 37216 is for carotid bifurcation stent placement (usually in smaller carotid
vessels) when an EPD is not used (or not possible to use). Medicare currently does not
reimburse for code 37216(carotid stent placement without embolic protection).
21. If an attempt to place the EPD fails, and the carotid stent is placed anways, use code
37216 (not 37215-74).
22. Code 37217 describes stent placement in the common carotid or brachiocephalic artery
when placed via open carotid access. This is an inpatient-only procedure.
23. Code 37218 describes stent placement in the common carotid or brachiocephalic artery
when placed via an antegrade approach (e.g., transfemoral access). This can be via open
or percutaneous access. This is an inpatient-only procedure.
24. Code 37236 describes stent placement in the right brachiocephalic artery when placed
via a right retrograde brachial approach.
25. Use code 37236 for percutaneous subclavian artery stent placement (also used for open
femoral or brachial approach).

26. Extracranial vertebral artery stent placement is reported with codes 0075T (initial) and
0076T (each additional). These codes expire January 2020. Use code 37217 when
common carotid stent placement is via ipsilateral carotid cutdown, and use code 37218
when common carotid stent placement is via an antegrade (e.g., femoral access)
approach.

27. For carotid stenting, append a -50 modifier to code 37215 or 37216 if the procedure is
performed bilaterally.

28. Cervical carotid stenting (37215) is an inpatient-only (status indicator C) procedure for
Medicare.

29. Cervical carotid stenting (37216) is status indicator E for Medicare. Discuss with your
payer.

30. Vertebral extracranial stenting (0075T, 0076T) is status indicator E for Medicare. Discuss
with your payer.

31. Intracranial, carotid, and vertebral stenting (61635, 37799, 37215, 37216, 37217, 37218,
0075T, 0076T) bundle ipsilateral catheter placement, diagnostic imaging of the
ipsilateral cervical and cerebral vessels (which includes IVUS), angioplasty, stenting, and
follow-up imaging into the single, all-inclusive code. Arch and other vessel imaging and
catheter selection may be coded if medically necessary with appropriate modifier for
the above listed codes, except code 37217 (which bundles arch imaging code 36221).

32. Code for diagnostic angiography prior to intervention if recent diagnostic angiogram has
not been performed [-59 modifier required on diagnostic angiography (S&I codes) at the
time of intervention] if there is a change in clinical status prior to the intervention or if
there is a change in clinical status in a vascular distribution distant from the site of
intervention. This does not apply to stent codes 37215, 37216, 37217, 37218, 0075T,
0076T, and 61635.

33. Do not code carotid stent placement (37215 or 37216) for Neuroform, Enterprise, LVIS,
and LVIS Jr. stent placement. These stents may be placed across a wide-mouthed
aneurysm of the high internal carotid artery and used as a lattice work to safely deploy
coils during aneurysm embolization procedures. If placed at time of embolization, it is
bundled. If placed on a separate date, use code 61635 for non-Medicare patients and
use -58 modifier for staged procedure (physician only) on subsequent embolization code
61624. Do not use code 61635 for Medicare due to CMS guidelines that require
documentation of atherosclerotic stenosis. Discuss this with your payer.

34. Vertebral and carotid artery angioplasty are considered experimental and are
non-covered services for Medicare. Use code 37246 to report carotid or vertebral
angioplasty without stent placement. Consider adding -GZ modifier to indicate this
procedure is non-covered. Since February 5, 2007, CMS (per NCD 20.7) has
implemented coverage for intracranial angioplasty and stent placement when cerebral
artery stenosis is > 50% in patients with intracranial atherosclerotic disease when
furnished in accordance with FDA-approved protocols governing Category B IDE clinical
trials. (See the coding instruction below, as the Wingspan requires a 70% stenosis.)

These are inpatient-only procedures for hospitals. Physicians report codes 61630 and
61635. These codes have restricted coverage and are priced by the Medicare Contractor
for physician reimbursement. Hospitals use code 37799 (per the Medicare Claims
Processing Manual) when stenting is performed in accordance with these FDA protocols.
35. Effective 8/2012, the Wingspan intracranial stent is approved for patients 22-80 years
old who meet the following criteria: 1) patient has had two or more strokes despite
aggressive medical therapy, 2) patient's most recent stroke occurred more than seven
days ago, 3) strokes are related to intracranial arterial stenosis of 70-99%, and 4) patient
has made a good recovery from previous stroke and has a modifier Rankin score of
three or less. The patient must not be treated with intracranial stent therapy if he/she
has had onset of stroke symptoms within the last seven days. This treatment is not for
the treatment of transient ischemic attacks (TIAs). Please follow Medicare Claims
Processing Manual guidance for billing purposes.
36. The Pipeline embolization device (flow diverter) is used to treat similar intracranial
aneurysms and may be coded as an embolization procedure (61624). The Pipeline is
FDA-approved as a new class of embolization device. The Surpass and FRED (Flow
Re-Direction Endoluminal Device) are additional flow-diverting embolization devices
undergoing clinical trials. A grey zone exists with utilization of this FDA-approved
embolization device. If considered a stent by your payer, code 61635 may be applicable.
This should be discussed with your payer.

EXAMPLE(S):

1) Patient with known abdominal aortic stenosis presents for stent placement. A catheter is
advanced from the right femoral artery to the aorta (36200), and aortography confirms the
stenosis (no code). Pre-dilation with an 8 mm balloon (no code) is performed followed by
placement of a 14 mm stent (37236). The stent is post-dilated to 16 mm (no code). Follow-up
angiography shows excellent results (no code).

2) Patient with right common carotid origin and right proximal vertebral stenoses presents for
stent placements. This is performed from a transfemoral approach. The catheter is placed across
each stenosis (no codes, as catheter placement is bundled) and stent deployment performed
twice [0075T (initial extracranial vertebral artery), 37218 (innominate or intrathoracic common
carotid artery stent placement via antegrade approach)]. Follow-up angiography shows widely
patent vessels (included).

3) Patient with vertebrobasilar insufficiency, drop attacks, and vertebral steal phenomenon on
Doppler ultrasound with retrograde flow in the left vertebral artery. Via a transfemoral route, a
catheter is advanced to the arch, and arch angiography is performed (36221). High grade
proximal subclavian artery stenosis is noted but is unable to be crossed from this approach. A
left brachial puncture is made, and a catheter and wire are advanced into the aorta across the
stenosis (36200-59). Primary angioplasty (37246) is attempted with a 7 mm balloon. Follow-up
angiography (no codes) shows residual 60% stenosis, so a stent is placed successfully (add
37236, delete 37246).

4) Dialysis patient with poorly functioning AV shunt undergoes diagnostic study (36901) after a
single puncture of the graft. This shows a 90% stenosis in the subclavian vein and a separate
stenosis in the basilic vein. Venoplasty (add 36902, 36907; delete 36901) is performed at both
sites via the dialysis circuit access. Follow-up imaging shows severe recoil in the subclavian vein,
so a stent is placed via the dialysis circuit access (add 36908, delete 36907). Post stent
placement angioplasty (not coded) to fully deploy the stent gives excellent results.

5) Patient with right carotid bifurcation stenosis on MRI. Via a right transfemoral approach, a
catheter is placed in the right common carotid artery, and a diagnostic angiogram is performed
(catheter placement imaging and follow-up are bundled into the carotid stent code). The
stenosis is confirmed, and a filter wire/stent deployment device successfully crosses the lesion.
The filter is deployed, followed by the stent (37215) and subsequent dilation with a balloon.
Both the filter and balloon are removed. Follow-up angiography shows excellent placement.

Note: Ipsilateral imaging, catheter placement, angioplasty, stenting, and follow-up angiography
are bundled into the carotid stenting codes. Cervicocerebral arch imaging (36221) may be
submitted if diagnostic angiography not previously performed.

7 Vascular Interventional Coding

Lower Extremity Endovascular Revascularization

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
As the complexities of interventional procedures used to improve blood flow through blocked
arteries have increased over time, so has the complexity of CPT coding. A code set was
developed to address procedural coding for these lower extremity arterial interventions. The
vessels involved with this code set include the iliac, femoral/popliteal, and tibial/peroneal
arteries. These codes only address angioplasty, atherectomy, and stent placement in the lower
extremity arteries. The codes include both open or percutaneous approaches, eliminating many
infrequently used codes. The guidelines created for these are specific for arterial territories: the
iliac, femoral/popliteal, and tibial/peroneal. The iliac territory includes three separately coded
vessels: the common iliac, external iliac, and internal iliac arteries. The femoral/popliteal
territory includes the common femoral, profunda femoral, superficial femoral, and popliteal
arteries, which are described as single vessels and are reported with a single code. The
tibial/peroneal territory includes three separately coded vessels: the anterior tibial, posterior
tibial, and peroneal arteries. The tibial/peroneal trunk is considered bundled with any distal
posterior tibial/peroneal intervention. Angioplasty can be performed with any type of balloon

(compliant, non-compliant, cutting, cryo, etc.). Atherectomy may utilize a photo ablation (laser),
cutting, or rotational device to remove atheroma, while stent placement may use a
self-expanding, balloon expandable, drug-eluting, or covered stent. Guidelines vary based on
the territory in which the procedure is performed. A Category III code is necessary to describe
atherectomy procedures in the iliac territory. The lower extremity revascularization code set is
specific to use for treatment of occlusive disease and bundles supervision and interpretation for
the intervention (including guiding, intraprocedural, and completion imaging), vascular access,
catheter placement across the lesion, use of an embolic protection device, and placement of a
closure device at the end of the procedure.

CLINICAL INDICATIONS:
Lower extremity vascular ischemia. This may be related to progressive atherosclerosis,
intimal hyperplasia, fibromuscular dysplasia, dissection, etc. The blockages may be partial or
complete, acute (as in a dissection), chronic, or recurrent.

CODES:

PROCEDURE DESCRIPTION PROC CODE T S
O &I
A TA C
PL O
CR D
V E
U

Iliac Territory

Revascularization, endovascular, open or percutaneous, iliac 37220 5 11 B
artery, unilateral, initial vessel; with transluminal angioplasty 1 .7 u
9 2 n
2 dl
e
d

Revascularization, endovascular, open or percutaneous, iliac 37221 5 14 B
artery, unilateral, initial vessel; with transluminal stent 1 .4 u
placement(s), includes angioplasty within the same vessel, when 9 6 n
performed 3 dl
e
d

Revascularization, endovascular, open or percutaneous, iliac N 5. B
artery, each additional ipsilateral iliac vessel; with transluminal / 45 u
angioplasty (List separately in addition to code for primary A n
procedure) dl
37222 e
d

Revascularization, endovascular, open or percutaneous, iliac N 6. B
artery, each additional ipsilateral iliac vessel; with transluminal / 23 u
stent placement(s), includes angioplasty within the same vessel, A n
when performed (List separately in addition to code for primary dl
procedure) 37223 e
Femoral/Popliteal Territory d

Revascularization, endovascular, open or percutaneous, femoral, 37224 5 12 B
popliteal artery(s), unilateral; with transluminal angioplasty 1 .9 u
9 7 n
2 dl
e
d

Revascularization, endovascular, open or percutaneous, femoral, 5 17 B
popliteal artery(s), unilateral; with atherectomy, includes 37225 1 .6 u
angioplasty within the same vessel, when performed 9 9 n
3 dl
e
d

Revascularization, endovascular, open or percutaneous, femoral, 37226 5 15 B
popliteal artery(s), unilateral; with transluminal stent 1 .2 u
placement(s), includes angioplasty within the same vessel, when 9 5 n
performed 3 dl
e
d

Revascularization, endovascular, open or percutaneous, femoral, 37227 5 21 B
popliteal artery(s), unilateral; with transluminal stent 1 .2 u
placement(s) and atherectomy, includes angioplasty within the 9 6 n
same vessel, when performed 4 dl
e
d

Tibial/Peroneal Territory

Revascularization, endovascular, open or percutaneous, tibial, 37228 5 15 B
peroneal artery, unilateral, initial vessel; with transluminal 1 .8 u
angioplasty 9 8 n
3 dl
e
d

Revascularization, endovascular, open or percutaneous, tibial, 37229 5 20 B
peroneal artery, unilateral, initial vessel; with atherectomy, 1 .6 u
includes angioplasty within the same vessel, when performed 9 2 n
4 dl
e
d

Revascularization, endovascular, open or percutaneous, tibial, 37230 5 20 B
peroneal artery, unilateral, initial vessel; with transluminal stent 1 .4 u
placement(s), includes angioplasty within the same vessel, when 9 1 n
performed 4 dl
e
d

Revascularization, endovascular, open or percutaneous, tibial, 37231 5 22 B
peroneal artery, unilateral, initial vessel; with transluminal stent 1 .1 u
placement(s) and atherectomy, includes angioplasty within the 9 7 n
same vessel, when performed 4 dl
e
d

Revascularization, endovascular, open or percutaneous, N 5. B
tibial/peroneal artery, unilateral, each additional vessel; with / 89 u
transluminal angioplasty (List separately in addition to code for A n
primary procedure) dl
37232 e
d

Revascularization, endovascular, open or percutaneous, N 9. B
tibial/peroneal artery, unilateral, each additional vessel; with / 60 u
atherectomy, includes angioplasty within the same vessel, when A n
performed (List separately in addition to code for primary dl
procedure) 37233 e
d

Revascularization, endovascular, open or percutaneous, N 8. B
tibial/peroneal artery, unilateral, each additional vessel; with / 33 u
transluminal stent placement(s), includes angioplasty within the A n
same vessel, when performed (List separately in addition to code dl
for primary procedure) 37234 e
d

Revascularization, endovascular, open or percutaneous, N 11 B
tibial/peroneal artery, unilateral, each additional vessel; with / .6 u
transluminal stent placement(s) and atherectomy, includes A8 n
angioplasty within the same vessel, when performed (List dl
separately in addition to code for primary procedure) 37235 e
37236 d
Transcatheter placement of an intravascular stent(s) (except
lower extremity artery(s) for occlusive disease, cervical carotid, 37237 5 13 B
extracranial vertebral or intrathoracic carotid, intracranial, or 1 .0 u
coronary), open or percutaneous, including radiological 9 0 n
supervision and interpretation and including all angioplasty 3 dl
within the same vessel, when performed; initial artery e
Transcatheter placement of an intravascular stent(s) (except d
lower extremity artery(s) for occlusive disease, cervical carotid,
extracranial vertebral or intrathoracic carotid, intracranial, or N 6. B
coronary), open or percutaneous, including radiological / 22 u
supervision and interpretation and including all angioplasty A n
within the same vessel, when performed; each additional artery dl
(List separately in addition to code for primary procedure) e
d

Transcatheter therapy, arterial infusion for thrombolysis other 37211 5 11 B
than coronary or intracranial, any method, including radiological 1 .2 u
supervision and interpretation, initial treatment day 8 1 n
4 dl
e
d

Transcatheter therapy, arterial or venous infusion for 37213 5 B
thrombolysis other than coronary, any method, including 1 6. u
radiological supervision and interpretation, continued treatment 8 79 n
on subsequent day during course of thrombolytic therapy, 2 dl
including follow-up catheter contrast injection, position change, e
or exchange, when performed; d

Transcatheter therapy, arterial or venous infusion for 37214 5 3. B
thrombolysis other than coronary, any method, including 1 56 u

radiological supervision and interpretation, continued treatment 8n
on subsequent day during course of thrombolytic therapy, 2 dl
including follow-up catheter contrast injection, position change,
or exchange, when performed; cessation of thrombolysis e
including removal of catheter and vessel closure by any method d

Primary percutaneous transluminal mechanical thrombectomy, 37184 5 13 B
noncoronary, non-intracranial, arterial or arterial bypass graft, 1 .0 u
including fluoroscopic guidance and intraprocedural 9 9 n
pharmacological thrombolytic injection(s); initial vessel 2 dl
e
d

Primary percutaneous transluminal mechanical thrombectomy, N 4. B
noncoronary, non-intracranial, arterial or arterial bypass graft, / 90 u
including fluoroscopic guidance and intraprocedural A n
pharmacological thrombolytic injection(s); second and all dl
subsequent vessel(s) within the same vascular family (List 37185 e
separately in addition to code for primary mechanical d
thrombectomy procedure)

Secondary percutaneous transluminal thrombectomy (eg, N 7. B
nonprimary mechanical, snare basket, suction technique), / 14 u
noncoronary, non-intracranial, arterial or arterial bypass graft, A n
including fluoroscopic guidance and intraprocedural dl
pharmacological thrombolytic injections, provided in conjunction 37186 e
with another percutaneous intervention other than primary d
mechanical thrombectomy (List separately in addition to code
for primary procedure)

Transluminal peripheral atherectomy, open or percutaneous, 5 B
including radiological supervision and interpretation; iliac artery, 0238T 1 0. u
each vessel 9 00 n
4 dl
e
d

Add-on Code

CODING INSTRUCTIONS:

298. Codes 37220, 37222, 37224, 37228, and 37232 are used when angioplasty only is
performed to open a blocked lower extremity artery.

299. Codes 37225, 37229, and 37233 are used when atherectomy (with or without
angioplasty) is performed to open a blocked lower extremity artery.

300. Code 0238T is used in addition to codes 37220-37223 if atherectomy along with
angioplasty or stent placement is performed in the iliac artery. Code 0238T can be used
up to three times per side, as there are three iliac arteries per side for coding purposes
(the common, internal, and external iliacs).

301. Codes 37221, 37223, 37226, 37230, and 37234 are used when stent placement (with
or without angioplasty) is performed to open a blocked lower extremity artery.

302. Codes 37227, 37231, and 37235 are used when both atherectomy and stent placement
(with or without angioplasty) are performed to open a blocked infrainguinal lower
extremity artery.

303. If both atherectomy and stent placement are performed in a single blocked iliac artery,
use codes 37221 and 0238T. If an additional iliac artery requires atherectomy and stent
placement, add codes 37223 and 0238T-59.

304. Do not submit any catheter placement codes for catheterization of an ipsilateral
extremity vessel once a code from 37220-37235 has been submitted for that extremity.

305. Submit catheter placement codes for visceral and upper extremity vessels selected,
unrelated to lower extremity revascularization procedures or when the lower extremity
vessels are treated for other than lower extremity revascularization of occlusive disease.

306. Submit catheter placement codes when used with iliac atherectomy (0238T), unless
other ipsilateral lower extremity revascularization codes are used.

307. If angioplasty is used to dilate a vessel, and a suboptimal result is obtained that
requires stent placement, the angioplasty is bundled in the codes for lower extremity
interventions. This is the same in the renals, viscerals, brachiocephalics, coronaries,
aorta, and venous system.

308. There is a hierarchy with the lower extremity revascularization codes. Stent with
atherectomy supersedes atherectomy, which supersedes stent, which supersedes
angioplasty when performed in the same vessel in the tibial/peroneal territory. If stent
placement is performed in one femoral/popliteal vessel, and atherectomy is performed
in a separate vessel in the ipsilateral femoral/popliteal distribution, use code 37227
(describes stent with atherectomy). Angioplasty is bundled with stent placement
procedures in the same vessel in the iliac, femoral/popliteal, and tibial/peroneal
territories.

309. If different stenoses in the same vessel are treated by different techniques, only code
the most complex combination treatment in the femoral/popliteal and tibial/peroneal
territories (e.g., stent with atherectomy). Only code once per vessel treated (see the
following coding instruction).

310. If angioplasty is used before or after atherectomy in the femoral/popliteal or

tibial/peroneal arteries, the angioplasty is bundled.
311. Angioplasty is bundled into lower extremity endovascular revascularization procedure

codes 37225-37227, 37229-37231, and 37233-37235.
312. Only bill the highest level intervention per vessel. There are three "vessels" in the iliac

territory, one "vessel" in the femoral/popliteal territory, and three "vessels" in the
tibial/peroneal territory for coding purposes. Iliac atherectomy may be separately
reported in addition to iliac angioplasty or stent placement codes.
313. The iliac territory is different, as iliac atherectomy (0238T) is additionally coded if
performed with other iliac interventions (angioplasty or stent placements 37220-37223).
314. The iliac territory includes three vessels that are separately coded: the common,
external, and internal iliac arteries.
315. The femoral/popliteal territory is coded only for the highest level of intervention
performed in any one or all of the common, profunda, or superficial femoral or popliteal
arteries in one extremity. Even if multiple femoral/popliteal vessels are intervened on,
only code one intervention total [e.g., if SFA angioplasty and stent, common femoral
and profunda femoral angioplasty, and laser atherectomy with angioplasty and stent in
the popliteal artery are all performed (four vessels, seven types of intervention), only
submit one code, the most complex highest level code 37227, for the stent with
atherectomy, including angioplasty (if done) in the femoral/popliteal territory].
316. The tibial/peroneal territory includes three vessels that are separately coded: the
anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is
considered part of any distal vessel intervention in the posterior tibial and peroneal
arteries. The tibial/peroneal trunk is considered a separate vessel from the anterior
tibial artery. The dorsalis pedis is considered part of the anterior tibial artery, and the
medial malleolar artery is considered part of the posterior tibial artery.
317. Only use the "initial" vessel code once per unilateral lower extremity territory. If
additional vessel interventions are done in the iliac or tibial/peroneal vessels, use the
ipsilateral "additional" intervention add-on codes.
318. Use the "initial" code to describe the most complex single vessel intervention
performed in a single vascular territory. Use the "additional" codes to describe lesser or
equally complex interventions in other vessels in that same territory (this does not apply
to the femoral/popliteal territory, as this entire territory is considered one vessel for
coding purposes).
319. Use one "initial" lower extremity revascularization code for each vascular territory for
each leg involved. Potentially, there could be six initial interventions if all three
territories were revascularized bilaterally.
320. Use the "additional" interventional add-on codes up to two times in each of the
ipsilateral iliac and tibial/peroneal territories. These add-on codes should not be used
more than twice for each territory of the same leg.
321. If interventions are performed in the other leg at the same setting, use the same code

set, but add modifier -50 or -59 to the "other leg" codes as appropriate (e.g., for
bilateral common iliac stent placement, use code 37221-50; for right common iliac stent
and left common iliac angioplasty, use codes 37221, 37220-59).
322. Do not code for vascular access or selective catheter placement in vessels described by
codes 37220-37235. Catheter placements are bundled.
323. Do not code for recanalization of lower extremity stenoses or occlusions, even if by
subintimal technique. Crossing the lesion is bundled with codes 37220-37235. The
angioplasty, atherectomy, or stent placement procedure is coded. The "Crosser"
catheter is considered an atherectomy device (FDA-approved as such), so use
appropriate atherectomy code when supporting documentation is submitted.
324. Do not code for use of an embolic protection device (EPD). This is bundled.
325. Do not report closure device placement with codes 37220-37235. This is bundled,
along with any imaging to evaluate a vessel for potential use of a closure device. Do not
code for surgical closure of the arteriotomy for "open" procedures.
326. Do not code for imaging related to guidance, localization, measurement, pre or post
intervention, as this imaging is bundled.
327. There are no S&I codes for lower extremity revascularization procedures described by
codes 37220-37235.
328. Separately code diagnostic imaging (when medically necessary) if not recently
performed. Do not code diagnostic imaging when merely for "confirmation" of a known
lesion seen on prior catheter-based angiography, diagnostic CTA, or MRA of the area of
interest. Do code diagnostic angiography if the area of interest was not included or
completely imaged on the prior study or if the prior study had significant limitations,
requiring repeat, catheter-based angiography. This must be clearly documented.
329. Code bridging lesions as a single vessel intervention, even if the bridging is between
different vascular territories (e.g., popliteal angioplasty with stent placement extending
into the proximal tibial/peroneal trunk; only report one stent placement code for the
most distal vessel stented -37230). If a single stent is deployed, only one procedure can
be coded (even if a long stent treats two separate lesions in two vessels).
330. In the femoral/popliteal territory, review all interventions performed in all four vessels
(common femoral, profunda femoral, superficial femoral, and popliteal), and code for
the highest level combined intervention as if done in one vessel. For example, if
angioplasty is performed in the common femoral, stent placement is performed in the
superficial femoral, and atherectomy is performed in the popliteal, all as separate
therapies, use code 37227. This code describes stent placement with atherectomy,
including angioplasty if done. All three types of intervention were performed in the
same femoral/popliteal territory, which is considered as a single vessel for coding
purposes.
331. If kissing stents (or angioplasty) are performed at the aortic bifurcation, append a -50
modifier to the initial vessel intervention code. If kissing stents (or angioplasty) are

performed at the iliac bifurcation, use one initial vessel code and one additional vessel
intervention code as appropriate for the proximal external iliac and proximal internal
iliac interventions. If done in the femoral/popliteal territory (such as angioplasty in the
profunda femoral and superficial femoral arteries extending back into the common
femoral), only submit one femoral/popliteal code. Note: The iliac bifurcation refers to
the location where the common iliac artery divides into the internal and external iliac
arteries.
332. Report percutaneous arterial thrombectomy codes 37184-37186 if done in the lower
extremities. Do not code the catheter placements if done at the same session as codes
37220-37235. You are not allowed to submit any catheter placements in the same lower
extremity at the same session as the revascularization codes.
333. Do not report code 37184 for thrombectomy when atherectomy is also performed in
the same vessel with the same device. Only code for the atherectomy.
334. Code catheter-directed thrombolytic infusion therapy separately (37211-37214). Do
not code for empiric injection of thrombolytics.
335. When performed, code separately for lower extremity arterial embolization
procedures using codes 37242-37244.
336. Codes 37220-37235 are used for both percutaneous and open endovascular
procedures.
337. Do not code for treatment of two separate lesions, by two different techniques, in the
same vessel, with two codes. Only code the highest level of intervention combination
performed. Only code one intervention per vessel (the femoral/popliteal territory is
considered one vessel), regardless of the number of lesions present. The exception to
this is iliac territory atherectomy, which may be billed in addition to codes 37220-37223.
338. Do not code multiple stent codes for placement of multiple stents in the same vessel.
Code per vessel, not per stent placed. In the femoral/popliteal territory, only one code is
submitted, regardless of the number of stents placed or vessels treated in that territory.
339. Laser atherectomy is FDA-approved for use in infrainguinal arteries and is coded as an
atherectomy procedure.
340. Report only two angioplasties (right and left iliac) with codes 37220-50 when kissing
angioplasty is performed at the aortic bifurcation for adjacent distal aortic and proximal
bilateral proximal common iliac disease. Use code 37221-50 when kissing iliac stents are
placed for the same indication. This is for treatment of a bridging lesion between the
aorta and common iliac arteries. Do not code aortic angioplasty or stent placement
unless a separate and distinct aortic stenosis is additionally treated with a separate
stent.
341. Only code one angioplasty when performed in a bypass graft (e.g., femoral-tibial
bypass graft), even if both the proximal and distal anastomoses are treated with
angioplasty technique. The entire graft is one vessel for coding purposes.
342. If a bypass graft is in place, code the intervention, and first time medically necessary

diagnostic imaging, based on the vessel it is replacing [e.g., if a femoral/popliteal insitu
saphenous vein bypass graft is placed, and contralateral selection and angioplasty
(37224) are performed, use codes that describe the intervention in the artery, not the
vein, as this graft is "arterialized"].
343. Code infrainguinal "laser angioplasty" as an atherectomy. Use the lower extremity
atherectomy codes (37225, 37227, 37229, 37231, 37233, and 37235) for laser
atherectomy as appropriate when performed in the peripheral vasculature of the lower
extremities with or without stent placement. Do not code for laser atherectomy in
visceral or iliac vessels, as the procedure is currently only approved for use in
infrainguinal vessels.
344. Stents may be used to assist in therapy related to aortic or iliac stent grafting (e.g., for
aneurysm); however, stent placement can only be coded when performed outside the
stent graft deployment zone.
345. Stenting or angioplasty in the zone (same vessel) of treatment of an aortic or iliac stent
graft (e.g., for aneurysm) is included in the codes for the stent graft.
346. Subintimal recanalization of peripheral vessels is quite common. Many are now
performed with angioplasty alone and are quite successful without a stent, even in
superficial femoral artery occlusions. Use the appropriate endovascular
revascularization code here.
347. Delayed unilateral iliac or abdominal aortic stent graft extension device placement for
aortic aneurysm repair is reported with code 34710. Add code 34711 if performed in
two vessels (e.g., both iliacs or one iliac and the aorta). Use code 34709 if an extension is
placed at the time of EVAR placement. Endograft extension code 34709 does not apply
to extensions terminating in the EVAR landing vessel (e.g., common iliac arteries) at the
same session as implantation of EVAR. These codes are inpatient-only (status indicator
C).
348. Ilio-iliac tube endografts placed for iliac aneurysm, pseudoaneurysm, AVM, dissection,
or trauma are coded with 34707, 34708, or 0254T. If an aorto-bi-iliac stent graft is
placed to treat bilateral iliac aneurysms, use code 34705 or 34706. When a stent or
stent graft is placed in the femoral/popliteal or tibial/peroneal arteries for
"non-occlusive" disease, such as aneurysm, AVM, trauma, or rupture, use code 37236
and the appropriate selective catheter placement code.
349. Stent grafts placed for treatment of vessel rupture after initial angioplasty or stent
graft placement for treatment of vascular stenosis or occlusion in the iliac artery are
coded with the 2018 iliac endograft codes for rupture (e.g., 34708). This is a new
guideline for 2018. Code 34708 requires placement of a stent graft.
350. Report stent placement codes (37221, 37223) when a stent graft is placed in an iliac
artery to treat stenosis. In the iliac artery, use codes 34705-34708 when a stent graft is
placed to treat an aneurysm, pseudoaneurysm, dissection, AVM, AV fistula, or vascular
trauma.
351. Use code 37236 and selective catheter placement for stent graft placement in a

popliteal artery to treat an aneurysm, AV malformation, AV fistula, or vascular trauma.
352. If stent grafts are placed for treatment of both stenosis and aneurysm in the same

vessel, only submit the code for the primary indication (e.g., either code 37226 for
fem-pop stenosis or code 37236 for fem-pop aneurysm, but not both).
353. Do not code angioplasty within the stent graft deployment zone vessel for aortic or
iliac stent graft placement when done for aneurysm, etc. This includes the situation
where the intent was an iliac angioplasty for stenosis; however, the vessel ruptured and
required an iliac stent graft placement. This is a new guideline for 2018. In this case, the
iliac stent graft deployment is reported with code 34708 for iliac rupture. The
angioplasty is never coded in the same vessel as a stent placement.
354. Ultrasound guidance for vascular access (76937) may be reported in addition to lower
extremity revascularization procedures when there is medical necessity and all
necessary elements are documented. Code 76937 is bundled when the large
percutaneous access code (34713) is reported for the same vessel.
355. Code catheter placement separately for tPA infusion in a lower extremity artery if the
intervention (angioplasty/atherectomy/stent placement) is performed at a separate
session on the same date of service or on a different date of service.
356. Use codes 36901-36909 for angiography, angioplasty, stent placement, thrombectomy,
and/or venous branch embolization related to lower (or upper) extremity dialysis circuit
intervention via dialysis circuit access.

EXAMPLE(S):

1) 80-year-old with left leg claudication. A catheter is advanced from the right groin into the left
common iliac artery, and left leg angiography is performed (75710-59). Five separate 80%
stenoses in the superficial femoral and popliteal arteries are seen. Angioplasty of all five lesions
is performed with a 5 mm balloon (37224). Follow-up angiography shows good results (no
additional codes).
Note: Code angioplasty per territory treated, not per lesion, as this is in the femoral/popliteal
territory. Catheter placement and S&I are bundled.

2) Patient with known distal aortic and bilateral common iliac origin stenoses presents for
intervention. Bilateral punctures are made with advancement of two balloon catheters into the
aorta. Angiography confirms the two stenoses (no additional code). Balloon angioplasty is
performed simultaneously (37220-50) with good results.
Note: Do not additionally code for the contiguous distal aortic stenosis, as it is considered a
"bridging lesion" or extension of the disease treated with the bilateral kissing balloons. Catheter
placements and S&I are bundled.

3) Via an antegrade approach, angioplasty is performed of superficial femoral artery (37224),
popliteal artery (included), anterior tibial artery (37228), and posterior tibial artery (37232)
stenoses. These stenoses are separate, distinct, focal, and severe in nature.

Note: Catheter placements and S&I are bundled. Only use one code for all interventions in the
femoral/popliteal territory.

4) Via cutdown and after dissection and vessel loop placement, a catheter is advanced across an
iliac stenosis into the aorta. Angioplasty with an 8 mm balloon is performed (37220). Layered
closure of the cutdown is performed.

Note: Codes 37220-37235 are for open or percutaneous approach. Catheter placements, S&I,
and closure of the incision are bundled.

5) 60-year-old male undergoes surgical cutdown of the common femoral artery with placement
of a Silver Hawk atherectomy device down to the popliteal artery. Atherectomy is performed of
an eccentric plaque in the popliteal artery (37225). A Crosser catheter is then used as an
atherectomy device to recanalize a totally occluded posterior tibial artery (37229).

6) 75-year-old female with prior angiogram showing total occlusion of the SFA, stenotic
popliteal artery, and occlusion of the anterior tibial, tibial/peroneal trunk, and posterior tibial
arteries. Antegrade percutaneous puncture with Excimer laser recanalization of the SFA and
both tibial arteries is performed with a 2.0 mm device (37229, 37233). Atherectomy results in
numerous flow-limiting dissections in the SFA, so five stents are placed (37227). The popliteal
artery is treated with angioplasty alone (bundled). The tibial vessels require no further
treatment. (The tibial/peroneal trunk is considered part of the posterior tibial artery in this
example.)

7) Patient with left leg claudication and left SFA occlusion by recent right Doppler study. Patient
had prior stent placements in the SFA. From a femoral approach, a sheath is placed over the
bifurcation into the left common femoral artery. Angiogram of the left leg (75710-59) shows
complete occlusion of the SFA 2 cm beyond the origin with reconstitution of the SFA at Hunter's
Canal. The occlusion is within two of the prior SFA stents and most likely represents intimal
hyperplasia. A "Lumend" device is used to recanalize the occluded stent (this is not an
atherectomy). Cutting balloon angioplasty with a 5 mm "Angiosculpt" is performed throughout
the length of the occlusion (this is not an atherectomy; this is an angioplasty procedure coded
with 37224), followed by use of three drug-eluting balloons in the areas of recurrent stenosis
(hospitals bill device code C2623 x 3). Post-angioplasty angiography shows evidence of
dissection; however, flow is good, and no further intervention is warranted.

Note: Although code C2623 is not reimbursed by Medicare in 2018, ongoing data collection for
codes C2623 and 37224 will be done to determine if device payment should be reinitiated.

8) Patient with left hip claudication. Via right transfemoral route, the patient undergoes an
abdominal aortogram with catheter at the level of the renals (75625), followed by repositioning
of the catheter and complete bilateral lower extremity run-off (75716-59). Aortography shows
patent renal arteries and a normal aorta. Mid left common iliac and separate distal left external
iliac high grade stenoses are seen. The trifurcation vessels are patent. The sheath is advanced
over the horn (aortic bifurcation) to the left common femoral level, and a single 9 cm x 10 mm
long self-expanding stent is deployed across both lesions (37221). Post-deployment angiography
(no codes) shows good results.

Note: Had two stents been placed, two stent procedures would be coded. CPT guidelines

require that lesion treatments in adjacent vessels with a single stent are described by a single
stent placement code. The same single code would be reported for treatment of a bridging
lesion across two vessels.

9) Patient electively undergoes modular bifurcated abdominal aortic stent graft placement in
the abdominal aorta with additional unilateral right extension cuff into the mid external iliac
level (34705, 34709). To allow passage of the device, a stent is initially placed across a stenosis
in the right common iliac artery with excellent result (no codes, as this is in the stent graft
placement zone).

Note: Code 34812-50 would be added for bilateral femoral cutdowns. Bilateral non-selective
catheter placements into the aorta are bundled with code 34705.

10) Patient with left lower limb ischemia and thrombosed left femoral-popliteal bypass graft on
Doppler study. A sheath is placed via the right femoral approach, and a pigtail catheter is placed
at the level of the renals with abdominal aortography performed (75625). The catheter is pulled
down to the aortic bifurcation, and bilateral lower extremity angiography is performed
(75716-59). 100% occlusion of the native SFA and femoral-popliteal bypass graft is seen. A
Cobra catheter is advanced into the graft (36247), and thrombolysis is started (37211). The next
day, follow-up angiography (bundled) shows 90% stenosis of the distal anastomosis. A
Jetstream G3 device is used to perform atherectomy with 20% residual stenosis and good flow
(37225). The sheath is removed, and hemostasis is obtained (37214).

Neurovascular Interventional Procedures

7 Vascular Interventional Coding
Neurovascular Interventional Procedures Pages: 299-315

Procedure Example(s)
Clinical Indications References
Codes
Coding Instructions

PROCEDURE:
As technology has progressed and neurointerventionalists (endovascular physicians with
specialized training in neuro-oriented procedures) have developed new procedures and skills,
the coding has changed to keep up. The procedures commonly performed in this subspecialty
have been merged into this section of the book for quick reference. These procedures will be
described in this section as well as in the appropriate subsections of the book. The procedures
in this section include the endovascular procedures only. These endovascular procedures

include carotid, vertebral, and intracranial stenting; intracranial angioplasty; vasospasm therapy;
embolization procedures; venous sampling; thrombolysis; papaverine and verapamil infusion;
and arterial thrombectomy. All-inclusive codes for treatment of cerebral arteries for
embolic/thrombotic occlusion or vasospasm/chemo infusion have been developed.

CLINICAL INDICATIONS:
Loss of consciousness, seizure, stroke, atherosclerotic or fibromuscular vascular stenotic
disease, vasospasm, and subarachnoid hemorrhage caused by aneurysms or bleeding,
arteriovenous malformations, embolic events, or thrombosis of intracranial vessels.

CODES: PROC TS T
PROCEDURE DESCRIPTION CODE O& O
AT I AT
P AL C P AL
CR O CR
VD V
UE U

Venous catheterization for selective organ blood sampling 36500 N 5. 7 5
/ 31 5 1 0.
A 8 8 77
9 4
3

Thrombolysis, cerebral, by intravenous infusion 37195 5 B
6 0. u
9 00 n
4 dl
e
d

Transcatheter retrieval, percutaneous, of intravascular 37197 5 B
foreign body (eg, fractured venous or arterial catheter), 37212 1 8. u
includes radiological supervision and interpretation, and 8 77 n
imaging guidance (ultrasound or fluoroscopy), when 3 dl
performed e
Transcatheter therapy, venous infusion for thrombolysis, d
any method, including radiological supervision and
interpretation, initial treatment day 5 9. B
1 82 u
8 n
dl

3e
d

Transcatheter therapy, arterial or venous infusion for 37213 5 B
thrombolysis other than coronary, any method, including 1 6. u
radiological supervision and interpretation, continued 8 79 n
treatment on subsequent day during course of thrombolytic 2 dl
therapy, including follow-up catheter contrast injection, e
position change, or exchange, when performed; d

Transcatheter therapy, arterial or venous infusion for 37214 5 B
thrombolysis other than coronary, any method, including 1 3. u
radiological supervision and interpretation, continued 8 56 n
treatment on subsequent day during course of thrombolytic 2 dl
therapy, including follow-up catheter contrast injection, e
position change, or exchange, when performed; cessation d
of thrombolysis including removal of catheter and vessel
closure by any method

Transcatheter placement of intravascular stent(s), cervical ♦ 37215 N 29 B
carotid artery, open or percutaneous, including angioplasty, / .1 u
when performed, and radiological supervision and A8 n
interpretation; with distal embolic protection dl
e
d

Transcatheter placement of intravascular stent(s), cervical 37216 N 29 B
carotid artery, open or percutaneous, including angioplasty, / .3 u
when performed, and radiological supervision and A1 n
interpretation; without distal embolic protection dl
e
d

Transcatheter placement of intravascular stent(s), ♦ 37217 N 31 B
intrathoracic common carotid artery or innominate artery / .5 u
by retrograde treatment, open ipsilateral cervical carotid A3 n
artery exposure, including angioplasty, when performed, dl
and radiological supervision and interpretation e
d

Transcatheter placement of intravascular stent(s), ♦ 37218 N 23 B
intrathoracic common carotid artery or innominate artery, / .6 u
open or percutaneous antegrade approach, including A3 n
angioplasty, when performed, and radiological supervision dl
and interpretation e

d

Transcatheter placement of extracranial vertebral artery N 0. B
stent(s), including radiologic supervision and interpretation, ♦ 0075T / 00 u
open or percutaneous; initial vessel A n
dl
e
d

Transcatheter placement of extracranial vertebral artery ♦ N 0. B
stent(s), including radiologic supervision and interpretation, 0076T / 00 u
open or percutaneous; each additional vessel (List A n
separately in addition to code for primary procedure) dl
e
d

Transcatheter placement of an intravascular stent(s) 37236 5 13 B
(except lower extremity artery(s) for occlusive disease, 1 .0 u
cervical carotid, extracranial vertebral or intrathoracic 9 0 n
carotid, intracranial, or coronary), open or percutaneous, 3 dl
including radiological supervision and interpretation and e
including all angioplasty within the same vessel, when d
performed; initial artery

Transcatheter placement of an intravascular stent(s) N 6. B
(except lower extremity artery(s) for occlusive disease, / 22 u
cervical carotid, extracranial vertebral or intrathoracic A n
carotid, intracranial, or coronary), open or percutaneous, dl
including radiological supervision and interpretation and 37237 e
including all angioplasty within the same vessel, when d
performed; each additional artery (List separately in
addition to code for primary procedure)

Transcatheter placement of an intravascular stent(s), open 37238 5 B
or percutaneous, including radiological supervision and 1 8. u
interpretation and including angioplasty within the same 9 73 n
vessel, when performed; initial vein 3 dl
e
d

Transcatheter placement of an intravascular stent(s), open N 4. B
or percutaneous, including radiological supervision and / 43 u
interpretation and including angioplasty within the same A n
vessel, when performed; each additional vein (List dl
e

separately in addition to code for primary procedure) 37239 d
Transluminal balloon angioplasty (except lower extremity 37246
artery(ies) for occlusive disease, intracranial, coronary, 5 10 B
pulmonary, or dialysis circuit), open or percutaneous, 37247 1 .1 u
including all imaging and radiological supervision and 9 4 n
interpretation necessary to perform the angioplasty within 2 dl
the same artery; initial artery e
Transluminal balloon angioplasty (except lower extremity d
artery(ies) for occlusive disease, intracranial, coronary,
pulmonary, or dialysis circuit), open or percutaneous, N 4. B
including all imaging and radiological supervision and / 98 u
interpretation necessary to perform the angioplasty within A n
the same artery; each additional artery (List separately in dl
addition to code for primary procedure) e
d

Transluminal balloon angioplasty (except dialysis circuit), 37248 5 B
open or percutaneous, including all imaging and radiological 1 8. u
supervision and interpretation necessary to perform the 9 68 n
angioplasty within the same vein; initial vein 2 dl
e
d

Transluminal balloon angioplasty (except dialysis circuit), N 4. B
open or percutaneous, including all imaging and radiological / 22 u
supervision and interpretation necessary to perform the A n
angioplasty within the same vein; each additional vein (List dl
separately in addition to code for primary procedure) 37249 e
d

Intravascular ultrasound (noncoronary vessel) during N 2. B
diagnostic evaluation and/or therapeutic intervention, / 66 u
including radiological supervision and interpretation; initial A n
noncoronary vessel (List separately in addition to code for dl
primary procedure) 37252 e
d

Intravascular ultrasound (noncoronary vessel) during N 2. B
diagnostic evaluation and/or therapeutic intervention, / 14 u
including radiological supervision and interpretation; each A n
additional noncoronary vessel (List separately in addition to dl
code for primary procedure) 37253 e
d

Endovascular temporary balloon arterial occlusion, head or 61623 5 16 B

neck (extracranial/intracranial) including selective 1 .8 u
catheterization of vessel to be occluded, positioning and 90 n
inflation of occlusion balloon, concomitant neurological 3 dl
monitoring, and radiologic supervision and interpretation of
all angiography required for balloon occlusion and to e
exclude vascular injury post occlusion d

Transcatheter permanent occlusion or embolization (eg, for ♦ 61624 N 33 7 N 2.
tumor destruction, to achieve hemostasis, to occlude a / .5 5 / 05
vascular malformation), percutaneous, any method; central A8 8 A
nervous system (intracranial, spinal cord) 9
4

Transcatheter permanent occlusion or embolization (eg, for 61626 5 25 7 N 2.
tumor destruction, to achieve hemostasis, to occlude a 1 .1 5 / 05
vascular malformation), percutaneous, any method; 9 9 8 A
non-central nervous system, head or neck (extracranial, 3 9
brachiocephalic branch) 4

Angiography through existing catheter for follow-up study 7 5
for transcatheter therapy, embolization or infusion, other 5 1 2.
than for thrombolysis 8 8 56
9 2
8

Balloon angioplasty, intracranial (eg, atherosclerotic #♦ 61630 N 39 B
stenosis), percutaneous / .8 u
A1 n
dl
e
d

Transcatheter placement of intravascular stent(s), #♦ 61635 N 42 B
intracranial (eg, atherosclerotic stenosis), including balloon / .4 u
angioplasty, if performed A2 n
dl
e
d

Intracranial angioplasty or stent placement for treatment of 37799 5 B
> 50% atherosclerotic intracranial stenosis for Medicare 1 0. u
patient, if entered in an FDA-approved Class B-IDE clinical 8 00 n
trial 1 dl
e
d

Balloon dilatation of intracranial vasospasm, percutaneous; #61640 N 14 B
initial vessel / .0 u
A1 n
dl
e
d

# N 4. B
Balloon dilatation of intracranial vasospasm, percutaneous; / 92 u
each additional vessel in same vascular family (List A n
separately in addition to code for primary procedure) dl
e
61641 d
#
Balloon dilatation of intracranial vasospasm, percutaneous; N 9. B
each additional vessel in different vascular family (List / 84 u
separately in addition to code for primary procedure) A n
61642 dl
e
d

Percutaneous arterial transluminal mechanical ♦ 61645 N 24 B
thrombectomy and/or infusion for thrombolysis, / .0 u
intracranial, any method, including diagnostic angiography, A4 n
fluoroscopic guidance, catheter placement, and dl
intraprocedural pharmacological thrombolytic injection(s) e
d

Endovascular intracranial prolonged administration of ♦ 61650 N 15 B
pharmacologic agent(s) other than for thrombolysis, / .6 u
arterial, including catheter placement, diagnostic A6 n
angiography, and imaging guidance; initial vascular territory dl
e
d

Endovascular intracranial prolonged administration of N 6. B
pharmacologic agent(s) other than for thrombolysis, / 65 u
arterial, including catheter placement, diagnostic A n
angiography, and imaging guidance; each additional dl
vascular territory (List separately in addition to code for ♦ 61651 e
primary procedure) 95958 d
Wada activation test for hemispheric function, including
5 6.

electroencephalographic (EEG) monitoring 7 49
2
4

Add-on Code
♦ Inpatient-Only Procedure
# Restricted Coverage
Note: Codes 61630 and 61635 are covered as noted in coding instruction #6.

CODING INSTRUCTIONS:
357. There are three cerebral arterial territories for infusion therapy and/or endovascular
revascularization: the right and left hemispheres and the posterior fossa.
358. Use code 61630 for intracranial angioplasty for treatment of stenosis or occlusion
(unrelated to vasospasm).
359. Code 61630 includes catheter placement; imaging before, during, and after the
angioplasty; guiding; and sizing angiography of the vascular family treated.
360. Codes 61630 and 61635 are intended for treatment of atherosclerotic lesions. There
may be other indications that are payer-specific. Codes 61640, 61641, and 61642 are
intended for angioplasty treatment of vasospasm.
361. Use code 61635 for intracranial stent placement. This includes any associated
angioplasty, unless the angioplasty is performed in a separate vessel. Do not code an
angioplasty (61630) if performed in the same target vessel as a vessel treated with a
stent (61635). In this case, the codes are bundled.
362. Codes 61630 and 61635 include all imaging of the vascular family treated with balloon
or stent. Ipsilateral catheter placement is also bundled. Diagnostic arch angiography
(36221) may be separately coded, if medically necessary, and if a recent diagnostic
study has not been performed.
363. Vertebral and carotid artery angioplasty are considered experimental and are
non-covered services for Medicare. Use code 37246 to report carotid or vertebral
angioplasty without stent placement. Consider adding -GZ modifier to indicate this
procedure is non-covered. Since February 5, 2007, CMS (per NCD 20.7) has
implemented coverage for intracranial angioplasty and stent placement when cerebral
artery stenosis is > 50% in patients with intracranial atherosclerotic disease when
furnished in accordance with FDA-approved protocols governing Category B IDE clinical
trials. (See the coding instruction below, as the Wingspan requires a 70% stenosis.)
These are inpatient-only procedures for hospitals. Physicians report codes 61630 and
61635. These codes have restricted coverage and are priced by the Medicare Contractor

for physician reimbursement. Hospitals use code 37799 (per the Medicare Claims
Processing Manual) when stenting is performed in accordance with these FDA protocols.
364. Effective 8/2012, the Wingspan intracranial stent is approved for patients 22-80 years
old who meet the following criteria: 1) patient has had two or more strokes despite
aggressive medical therapy, 2) patient's most recent stroke occurred more than seven
days ago, 3) strokes are related to intracranial arterial stenosis of 70-99%, and 4) patient
has made a good recovery from previous stroke and has a modifier Rankin score of
three or less. The patient must not be treated with intracranial stent therapy if he/she
has had onset of stroke symptoms within the last seven days. This treatment is not for
the treatment of transient ischemic attacks (TIAs). Please follow Medicare Claims
Processing Manual guidance for billing purposes.
365. Code 95958 describes a Wada test. This involves injection or short infusion of a drug
into a portion of the brain via catheter. This includes EEG monitoring. The cerebral
imaging procedures are separately billable (e.g., code 36224-50 for bilateral carotid
cerebrals). Do not use code 61650 for injection of the sodium amytal or other drug into
the cerebral arteries for Wada testing. This is not an infusion therapy.
366. Code for any diagnostic angiography unrelated to intracranial angioplasty and stenting
(unaffected vascular families) and their catheter placements, along with cervicocerebral
arch angiography (if documented).
367. Code complete angiography if done and decision is made to not perform intra or
extracranial angioplasty or stenting based on the study. This is also true for non-covered
intra or extracranial angioplasty or stent placement.
368. Use code 61640 for the initial vessel treated by balloon angioplasty for vasospasm.
369. Use code 61641 for each additional branch of the same vascular family treated with
balloon angioplasty for vasospasm.
370. There are three separate vascular distributions for intracranial balloon vasospasm
therapy: the right internal carotid distribution, left internal carotid distribution, and the
posterior fossa, which is supplied by the right and left vertebral arteries.
371. Use code 61642 for vasospasm angioplasty treatment in additional vascular families. If
there are additional separate branch vessels treated in the additional vascular family,
use code 61641 for each additional branch.
372. Codes 61641 and 61642 are add-on codes.
373. Use code 61650 for initial cerebral arterial territory non-thrombolytic infusion therapy
(vasospasm treatment, chemotherapy infusion). Use code 61651 for each additional
cerebral territory.
374. Up to three territories can be treated at a single session. Add-on code 61651 can be
submitted up to a maximum of two times per date of service (even if more than one
session of treatment is necessary).
375. Codes 61650 and 61651 require "prolonged" drug administration of at least ten
minutes. This can be by continuous or intermittent infusion. Do not use these codes for

"injection" of drugs such as nitroglycerine or heparin.
376. Treatment of iatrogenically induced vasospasm is not separately coded (do not use

codes 61650 and 61651).
377. Treatment of iatrogenically induced cerebral arterial embolus is separately reported

with code 61645.
378. Follow-up angiography (75898) is not billed with thrombolysis codes 37211-37214 or

procedures described by codes 61645, 61650, and 61651. It is bundled.
379. Although infusion therapy codes do not have a specified time requirement for minimal

duration of infusion, some LCDs do have guidance for the time of infusion. Regardless,
never report an infusion procedure code for a transcatheter bolus or injection of a
thrombolytic or non-thrombolytic agent. An injection is not an infusion. Intracranial
administrations may be continuous or intermittent, but codes 61650 and 61651 only
apply when the drug administration duration is documented to be at least ten minutes.
380. Intracerebral vasospasm infusion codes 61650 and 61651 are used when drugs such as
papaverine, verapamil, vasopressin, nicardipine, nimodipine, and milrinone are
continuously or intermittently infused intracranially for at least ten minutes. A short
injection of these drugs to treat iatrogenically induced vasospasm is not coded.
Occasionally nitroglycerin is continuously infused overnight using catheter-directed
technique in patients with limb threatening ischemia; consider unlisted code 37799 here.
Intravenous (injection or bolus) administration of nitroglycerin is not considered a
non-thrombolytic infusion. Heparin administration is never considered an infusion
therapy. LCDs limit the appropriate indications for infusion therapy.
381. Do not use an interventional code to describe catheter-directed intra-arterial
non-cerebral chemotherapy infusion. Use code 61650 to describe catheter-directed
intracerebral chemotherapy infusion.
382. The timeline for intracranial infusions requires at least ten minutes of continuous or
intermittent administration of the medication (e.g., verapamil infusion into the cerebral
vasculature). Infusion therapy in the peripheral system may require hours (e.g., arterial
thrombolysis or vasoconstriction therapy) or days (e.g., venous thrombolysis) to
complete the therapy. Infusion therapy codes 37211 and 37212 specifically do not have
"time required" in the code definitions (however, codes 61650 and 61651 require ten
minutes of continuous or intermittent infusion). Injection or slow push of medication
over one or two minutes is not considered an infusion therapy.
383. Code 75898 applies only to follow-up or completion angiography in conjunction with
CNS and head and neck embolization codes 61624 and 61626. Do not submit with any
infusion therapy codes. Date of service MUEs limit the use of code 75898 to two times
per day. We will update if there are changes to the limitations of this policy on our
website.
384. Codes 61650 and 61651 are billed once per arterial cerebral territory. These territories
are the right and left cerebral vasculature and the posterior fossa when treatment is for
vasospasm or chemotherapy with separate catheterizations and infusions.

385. Codes 61650 and 61651 bundle vasospasm angioplasty codes 61640-61642.
386. Do not submit codes 61640, 61641, and 61642 with codes 61650 and 61651, as

vasospasm or chemotherapy balloon dilation is bundled with infusion codes 61650 and
61651.
387. Do not code for imaging for vasospasm angioplasty prior to the intervention if
diagnostic angiography is necessary to determine the course of action. All diagnostic
imaging, guidance, and follow-up are bundled with codes 61650 and 61651. Vasospasm
can result in rapid clinical change requiring repeat diagnostic imaging; however, this
imaging is bundled with infusion treatment.
388. Do not code for imaging related to guidance, intraprocedural work, or follow-up when
vasospasm angioplasty is performed.
389. If embolectomy or thrombectomy of an intracranial artery is performed with a Merci
Retrieval, Penumbra, Trevo, Solitaire, or other intracerebral thrombectomy device, use
code 61645 per cerebral territory. These codes include ipsilateral catheter placement,
imaging, the use of thrombolytics, and follow-up angiography.
390. If papaverine, verapamil, nimodipine, nicardipine, milrinone, or other similar
medication is infused for treatment of vasospasm by catheter-directed technique prior
to balloon angioplasty, use code 61650 for the initial cerebral artery territory. Use code
61651 for each additional territory (maximum of two).
391. Codes 61650 and 61651 are used for infusion of spasmolytics (to relieve vasospasm)
and chemotherapy. They may only be used to treat non-iatrogenic disease. Treatment
for iatrogenically-induced vasospasm (e.g., carotid stent placement results in distal ICA
vasospasm, requiring treatment with infusion of verapamil) is not reported.
392. Do not use codes 37211-37214 for cerebral thrombolytic infusions. Use code 61645 for
cerebral thrombolysis (including cerebral thrombectomy if done).
393. Codes 61645, 61650, and 61651 describe arterial procedures and bundle catheter
placement, diagnostic imaging, guidance, and follow-up (completion) imaging in the
same cerebral territory.
394. Use code 61645 for catheter-directed cerebral thrombolytic infusion therapy (per
territory). This includes thrombectomy and any means to revascularize an acutely
occluded intracranial artery. Code 61645 can also be submitted if only thrombectomy is
performed without thrombolytic infusion. This code is for revascularization by any
method to treat thrombus/embolus/occlusion of cerebral arteries and bundles
intracranial angioplasty (61630), intracranial stent placement (61635), and intracranial
vasospasm therapy (61650) in the same cerebral territory.
395. Do not report angioplasty or venoplasty codes 37246-37249 when angioplasty is
performed at the same session in the same vessel as a stent placement (e.g., do not
submit separate angioplasty with codes 36903, 36906, 36908, 37215-37218,
37220-37235, 61635, 92920-92944, 0075T, 0076T, or C9600-C9608).
396. Do not report catheter-directed thrombolytic (or non-thrombolytic) infusion therapy

codes for non-catheter-directed peripheral IV infusions. Use code 37195 for intracranial
and 92977 for coronary arterial thrombolysis by peripheral IV infusion.
397. Use code 37212 for initial day of cerebral venous thrombolytic infusion therapy.
398. Use code 37187 for initial day of cerebral venous thrombectomy.
399. Use code 37195 for intracranial thrombolysis by peripheral intravenous infusion. This is
usually performed in the emergency room by the nurse. Use code 61645 for
catheter-directed cerebral artery infusion for intracranial thrombolysis.
400. Do not submit codes 61645 and 61650 together. Submit either code 61645 or 61650
based on the primary intent of the procedure, but never both for the same cerebral
territory. If both are done in the same territory, only report code 61645.
401. Code 37211 is not used for cerebral artery thrombolysis. Use code 61645 instead.
402. Cerebral artery thrombectomy code 61645 bundles ipsilateral catheter placement,
diagnostic imaging, thrombolysis, intracerebral balloon angioplasty and/or stent
placement, vasospasm therapy, and follow-up imaging.
403. Additional arterial vessel thrombectomy (37185) refers to treatment of non-cerebral
thrombus in a separate and distinct vessel from the initially treated vessel, but in the
same vascular family. Commonly, this will be a vessel distal to the originally treated
vessel (e.g., the anterior tibial artery after a fem-pop bypass graft thrombectomy). This
is an add-on code to 37184. Code 37185 is used only once in the same vascular family,
even if several distal branches are selected and treated.
404. For codes 61645 (intracranial arterial revascularization) and 61650/61651 (intracranial
arterial continuous or intermittent non-thrombolytic infusion therapy), there are three
arterial territories: the right carotid, left carotid, and vertebrobasilar. Only one code can
be submitted per territory. These include catheter placement, diagnostic imaging, and
follow-up of the ipsilateral territory.
405. Follow-up angiography (75898) may be used with neuro embolotherapy codes (61624,
61626) and may be used as often as medically necessary to safely perform central
nervous system (CNS) embolizations performed by neurointerventionalists (61624);
however, due to CMS implementation of date of service MUEs for code 75898, you may
be limited to submitting this code two times per day. (Note: Code 75898 may only be
used once to describe all follow-up imaging with head and neck embolization code
61626.) Documentation must support these separate and distinct follow-up angiograms.
Code 75898 is bundled with percutaneous thrombectomy, thrombolysis, angioplasty,
atherectomy, stent placement, and non-CNS/non-head and neck embolizations.
406. Do not submit catheter placement codes for vasospasm drug infusion.
407. Use code 61645 for catheter-directed intracranial thrombolysis with or without
thrombectomy. This is a "revascularization by any method" code. Do not use code
37195, as this code is used to describe thrombolytic agent given from an intravenous
infusion (e.g., in the emergency room by the nurse).
408. Use code 37236 for percutaneous or open stent placement in the right subclavian or

left subclavian arteries or the brachiocephalic artery via a retrograde right brachial
approach. Use code 37217 for retrograde right brachiocephalic or common carotid
artery stent placement via carotid cutdown. Use code 37218 for antegrade right
brachiocephalic or common carotid artery stent placement (usually femoral or left
brachial approach). Do not use these codes for cervical carotid, vertebral, coronary, or
intracranial stents.
409. Code all catheter placements and diagnostic imaging with angioplasty codes
37246-37249 and stent codes 37236-37239. The brachiocephalic carotid, vertebral, and
intracranial codes bundle catheter placement, diagnostic imaging, and follow-up
angiography of the treated vessel.
410. Use code 37215 or 37216 for carotid bifurcation stent placement depending on the use
of an embolic protection device (EPD). Code 37215 includes use of embolic protection,
while code 37216 is for carotid bifurcation stent placement (usually in smaller carotid
vessels) when an EPD is not used (or not possible to use). Medicare currently does not
reimburse for code 37216 (carotid stent placement without embolic protection).
411. Carotid and vertebral IVUS (37252, 37253) can be reported for diagnostic and stent
placement procedures. Carotid and vertebral IVUS is reported at the same session as
carotid or vertebral artery stent placement (allowed with codes 37215, 37216, 37218,
0075T, and 0076T per CPT parentheticals for code 37252), as diagnostic imaging is
included with these stent procedures.
412. Use Category III codes 0075T and 0076T for stenting of vertebral arteries. These codes
include catheter placement, all imaging of the target vessel, and cerebral run-off, as well
as any pre or post stent placement angioplasty. These codes expire January 2020.
413. Code 37217 bundles arch imaging. Codes 37215 and 37216 allow coding for diagnostic
arch angiography.
414. Use code 37217 for open carotid access with stent placement in the right
brachiocephalic or either common carotid artery. This code includes access, catheter
placement, imaging (including the aorta), angioplasty, stent placement, and surgical
closure.
415. Use code 37218 for percutaneous or open antegrade stent placement in the right
brachiocephalic artery or either intrathoracic common carotid artery. This code includes
access, catheter placement, imaging (including the aorta), angioplasty, stent placement,
and surgical closure.
416. Use code 37236 for percutaneous or open retrograde stent placement in the right
brachiocephalic artery via a right brachial access. Code the imaging and catheter
placement in addition to code 37236.
417. Use code 61623 for carotid or vertebral test occlusion. This code includes catheter
placement, occlusion balloon inflations, imaging, and follow-up of the target vessel. It
also includes neurological and physiological monitoring of the patient during the exam.
This code can be used for head and neck, intracranial or extracranial arterial test
occlusion.

418. If a diagnostic study had not been performed prior to carotid test occlusion, it may be
billed separately; however, the ipsilateral catheter placement code would be bundled.

419. If carotid test occlusion (61623) is followed by permanent occlusion (e.g., with coils),
bill both procedures by adding codes 61624/75894 and follow-up imaging code 75898.
Code 75898 may be billed as many times as medically necessary to safely perform the
CNS embolization procedure; however, recent date of service MUEs may limit code
75898 to two times per day.

420. The Pipeline embolization device (flow diverter) is used to treat similar intracranial
aneurysms and may be coded as an embolization procedure (61624). The Pipeline is
FDA-approved as a new class of embolization device. The Surpass and FRED (Flow
Re-Direction Endoluminal Device) are additional flow-diverting embolization devices
undergoing clinical trials. A grey zone exists with utilization of this FDA-approved
embolization device. If considered a stent by your payer, code 61635 may be applicable.
This should be discussed with your payer.

421. Use codes 61624 and 61626 for permanent embolization for intracranial/intraspinal
lesions and extracranial head and neck lesions respectively. These codes donot bundle
catheter placement, diagnostic imaging, and post-embolization images, all of which may
be billed separately.

422. Do not report intracranial stent placement code 61635 for Neuroform, Enterprise, LVIS,
or LVIS Jr. stent placement at the same time as an embolization. These stents are placed
as a lattice work across a wide-mouthed aneurysm to allow trapping of the coils during
embolization. This stent placement is considered to be an integral part of the
embolization procedure and is not separately billable at the same setting.

423. If the Neuroform, Enterprise, LVIS, or LVIS Jr. stent is placed a few weeks ahead of time
to allow stabilization of the stent in the vessel, this may be billed with code 61635, then
the subsequent embolization should be reported with code 61624-58, indicating a
staged procedure for this complex embolization. This stent placement should be
discussed with your Medicare payer, as CMS has stated intracranial stenting is approved
only for treatment of atherosclerotic stenosis of intracranial vessels (the Wingspan stent
system has FDA approval - see guidelines in coding instruction #7) and if entered into a
Class B IDE study (effective February 2007). There is no stenosis in this example. This is a
grey zone, as societies currently recommend using code 61635 here.

424. Intracranial aneurysms are coded per surgical field. There are three intracranial surgical
fields (the right and left cerebral hemispheres and the cerebellum), so use codes
61624/75894 for intracranial aneurysms treated by percutaneous technique at the same
setting per surgical field. If there are two aneurysms treated on the same side (e.g., right
MCA and right pericallosal artery aneurysms treated via the right carotid approach), use
modifier -22 with code 61624. This would be an uncommon occurrence. If two
aneurysms are treated, one in each of two surgical fields, such as a basilar tip aneurysm
and a right supraclinoid ICA aneurysm, use code 61624 twice with the appropriate
modifier.

425. Use code 37197 (retrieval of intravascular foreign body) for retrieval of coils intended
for intracranial embolization that migrate into visceral or extremity vessels. A dedicated
retrieval or snare device may be used for this. Code the catheter placement in addition.
The S&I is bundled.

EXAMPLE(S):

1) 78-year-old with giant (2 cm) right aneurysm on recent angiogram. From a transfemoral
approach, a sheath is placed followed by guiding catheter placement into the right common
carotid artery. 8,000 units heparin is administered. The patient is monitored by a neurologist. An
occlusion balloon is placed over a wire into the internal carotid and inflated. The patient
tolerates this vascular occlusion twenty minutes without evidence of stroke or brain ischemia.
The balloon is deflated and removed. This is a successful balloon test occlusion (61623; this
bundles catheter placements, imaging, monitoring, and test occlusion). Decision is made prior to
this procedure that, if successful, a permanent embolization will be performed. This is performed
by placing a number of coils in a nest configuration to incite thrombosis (61624, 75894).
Follow-up angiography (75898) shows complete occlusion. The patient tolerates the procedure
well.

Note: Since catheter placement is bundled into the initial test occlusion, do not bill the catheter
placement for the permanent occlusion, as they are in the same vessel. Also, had multiple
follow-up exams (75898) been performed to monitor the progress and safety of the procedure,
code 75898 may be submitted up to two times.

2) 37-year-old with right frontal meningioma on CT scan. Via a transfemoral approach, arch
(36221), bilateral cervical carotid (add 36222-50, delete 36221), bilateral internal carotid
injections with cerebral imaging (add 36224-50, delete 36222-50), and bilateral external carotid
catheter placement with imaging (36227-50) show supply to the meningioma only from the
right external carotid injection. The arch exam shows bovine variant anatomy. The
microcatheter is then advanced into the internal maxillary artery where road map (no code)
shows the middle meningeal artery. This is selected, injected, and imaged, showing a
hypervascular mass in the right frontal region. No collaterals to the cerebral distribution are
seen - only to the tumor (included with 36227). Particle embolization is performed (61624,
75894) with follow-up angiography showing complete occlusion (75898). A meningioma is an
intracranial mass, even though it is treated via an external carotid approach.

3) 87-year-old with acute, unrelenting right nasal bleed. From a transfemoral approach, a pigtail
catheter is placed for arch exam (36221). This is replaced with a Simmons 2 catheter, which is
reformed down the contralateral leg (no code for reforming catheters) and is placed into the
right common carotid artery. Unilateral cervical carotid angiogram shows 70% ICA stenosis and
40% ECA stenosis proximally (add 36222, delete 36221). The external carotid is carefully crossed
with a microcatheter, and selective angiography is performed (36227). The catheter is advanced
into the internal maxillary artery, and imaging is performed, showing hypervascularity in the
nasal region (included with 36227). The abnormal bleeding vessel is seen on this right-sided
injection. This is embolized with larger PVA particles (61626, 75894) with cessation of flow on
angiographic follow-up imaging (75898). (Catheter placement is bundled.)

4) 75-year-old with two prior documented strokes in the right MCA distribution and MRI
suggesting right ICA stenosis and right M-1 segment of the middle cerebral artery stenosis. From
a transfemoral approach, a catheter is placed into the right carotid, and imaging is performed.
Both of these lesions are seen and are critical in nature. Decision to stent the carotid and
balloon the MCA is made. Temporary pacer is placed in case of bradycardia (not coded, as
preventative procedure only). Using distal embolic protection, preliminary ballooning of the ICA
stenosis, followed by stent deployment, results in a widely patent vessel (37215). Microwire and
balloon are then placed across the MCA stenosis and inflated (61630). Follow-up shows a 70%
residual stenosis with acute thrombotic complication with distal occlusion. A Concentric Solitaire
device is used to extract the clot (add 61645, delete 61630), followed by Wingspan stent
placement in the area of residual stenosis (no code, as intracranial balloon angioplasty and
intracerebral stent placement are bundled with intracranial arterial revascularization code
61645). Ten minutes delayed films show excellent results.

Note: All ipsilateral catheter placements, imaging, angioplasty, stent placement, and follow-up
imaging are bundled into revascularization code 61645.

5) 23-year-old unconscious male with evidence of subarachnoid hemorrhage on lumbar
puncture. Via a translumbar approach, selective bilateral internal carotid and bilateral vertebral
artery injections with imaging of the cerebral vasculature is performed (36224-50, 36226-50).
Anterior communicating artery aneurysm is seen with some spasm. This is successfully
embolized with several GDC coils (61624, 75894). Follow-up angiography is performed, is
medically necessary, and is documented with findings five times during this complex intracranial
embolization (75898, 75898-59 x 4).

Note: MUEs currently limit the use of code 75898 to two times per date of service.

6) Same patient as case #5. After becoming much more alert and talking, the patient is
unarousable the next morning. The patient is brought to CT scan, which shows no new bleeding.
He then has emergent bilateral selective vertebral and bilateral selective internal carotid
cerebral angiography (36224-50, 36226-50), showing severe vasospasm in both the right
anterior cerebral, callosal marginal, and pericallosal arteries as well as the left anterior cerebral
and middle cerebral arteries. All five of these vessels are treated with vasospasm balloon
angioplasty (61640, 61641, 61641 are used for billing the right ACA, pericallosal, and callosal
marginal arteries; 61642, 61642 are used for the left anterior and middle cerebral arteries).
Follow-up angiography bilaterally shows improved flow (no code, as follow-up angiography
bundled in vasospasm angioplasty codes).

Note: Medicare may not recognize codes 61640-61642. Discuss with your payer.

7) Same patient as above becomes somnolent two days later. Angiography is performed again
with catheter placement in the right and left internal carotid arteries with cerebral imaging
(36224-50). Vasospasm is seen on the right side only. Microcatheter is advanced into the right
MCA. Imaging shows severe vasospasm (36228) involving M2 superior and inferior branches.
Milrinone infusion is started (add 61650; delete 36228 and change modifier -50 to -59 for code
36224). This is continued for 20 minutes. Follow-up angiography (bundled) shows improvement.
The patient awakens on the table.

8) Patient with bilateral proximal vertebral and left common carotid origin stenosis on recent
angiogram presents for multiple stenting. Preliminary angiography confirms these lesions (no
code). Stents are then placed successfully in all three vessels via a transfemoral percutaneous
route (0075T, 0076T, 37218) without complication.

Note: All preliminary angiography, catheter placements, angioplasty, stent deployment, and
follow-up imaging are bundled. These are still inpatient-only procedures (status indicator C).
Use code 37217 when common carotid stent procedure is performed via open carotid
retrograde access, and use code 37236 when brachiocephalic stent procedure is performed via
open or percutaneous retrograde right brachial access.

9) Patient presents to ER with stroke symptoms for one hour. There is no access to a
neurointerventionalist for six hours. CT scan shows no hemorrhage. Intravenous infusion of 100
mg tPA is given by the nurse under physician guidance (37195).

10) Patient presents to ER with stroke symptoms for one hour. The "stroke center team" is called
on site. CT scan shows no hemorrhage. From a transfemoral approach, arch, bilateral cervical
carotid, and bilateral cerebral angiography (36224-50) are performed. Catheter placements are
in the internal carotid arteries and eventually the M-1 and three branches of M2 of the left
middle cerebral artery with imaging (36228). Clot is seen in the left ICA and MCA. Arch, cervical,
and right cerebral vessels are normal. A Solitaire device is advanced into the ICA, and
thrombectomy is performed (add 61645; delete 36228 and change modifier -50 to -59 for code
36224). The device is advanced into the M-1 segment of the MCA for further thrombectomy (no
additional code, as in the same territory). The device is advanced into the M-2 segment (no
additional code) and thrombectomy performed (no additional code). Intraprocedural
thrombolysis (during thrombectomy - bundled) is performed. Follow-up angiography (no code
for follow-up after thrombectomy) shows residual thrombus. For this reason, a microinfusion
catheter is utilized for 60 minutes additional thrombolysis (bundled). Follow-up shows resolution
of thrombus (bundled). The patient's symptoms resolve on the table.

Note: Do not add any additional imaging codes, even if the left anterior cerebral artery is also
selected and imaged.

11) Patient with questionable stenosis right proximal MCA on MRI study. From a transfemoral
approach, a catheter is placed for arch, then selective catheter placement into the right and left
common carotid and both vertebral arteries with imaging of the arch, both cervical carotids,
both cerebral carotids (36223-50), and both vertebral, cerebral, and cervical segments
(36226-50). (Catheter placements are bundled.) Filming shows all vessels to be normal. No stent
was placed. (Bill for the angiography and catheter placements, not an attempted stent
placement.)

12) Same patient as case #11, but 70% MCA stenosis is seen when unilateral imaging is
performed. This is stented with a 1.5 mm balloon-expandable stent without complication.
Follow-up imaging at 10 minutes shows continued patency (61635).

Note: All ipsilateral catheter placements, imaging, ballooning, stenting, and follow-up imaging
are included in code 61635. Delete code 36223-50, and add code 36223-59. For Medicare
patients, the physician and facility must be part of a Class B IDE for this service and the hospital