Lower Extremity Revascularization in 2026: A Practical Coding Playbook for Navigating Complexity, Compliance, and Revenue Integrity

The lower extremity revascularization (LER) code overhaul represents one of the most consequential CPT® restructurings interventional and vascular teams have faced in decades. What was once a relatively compact code family has evolved into a far more granular framework—one designed to better reflect modern endovascular practice, but also one that demands a much higher level of precision from physicians, coders, and compliance leaders.

This guide reframes the discussion away from “memorizing new codes” and toward understanding the logic behind the redesign. When teams grasp the why—territories, lesion complexity, hierarchy, and intent—the how becomes significantly more manageable.

Why This Overhaul Matters More Than Any Prior Update

Effective January 1, 2026, CPT® deleted codes 37220–37235 and replaced them with an expanded series 37254–37299. This change did more than add codes—it redefined how lower extremity disease is conceptualized, documented, and reimbursed.

Key structural shifts include:

• Expansion from 3 to 4 vascular territories
• Growth from 16 to 46 total codes
• Clear differentiation between stenosis (straightforward) and occlusion (complex)
• Introduction of technology-specific add-on codes, such as lithotripsy

For the first time, coding now closely mirrors real-world procedural complexity. That alignment is a long-term win—but only for organizations prepared to adapt.

The Three Core Challenges Practices Will Face

1. The Learning Curve Is Immediate and Steep

Moving from a limited code set to a highly stratified system will temporarily slow productivity. Coders, physicians, and billing teams must all learn simultaneously. Expect:

• Increased code selection uncertainty
• Slower chart turnaround
• Higher initial denial risk

2. Documentation Precision Becomes Non-Negotiable

The new structure cannot function without explicit documentation. If the operative note does not clearly state:

• Which territory was treated
• Which specific artery was involved
• Whether the lesion was stenotic or occlusive
  • then correct coding becomes impossible—introducing both compliance risk and revenue leakage.

3. Payer and Auditor Lag

History tells us that payers rarely keep pace with sweeping CPT® changes. Early 2026 is likely to bring:

• System edits not fully updated
• Inconsistent payer interpretations
• Increased audits driven by unfamiliarity rather than error

What the New LER Codes Include by Design

The lower extremity endovascular revascularization codes describe percutaneous and open access interventions for occlusive disease and include:

• Vascular access and selective catheterization
• Lesion traversal (when successful)
• The definitive endovascular intervention
• All intraprocedural imaging and radiological supervision
• Embolic protection (when used)
• Arteriotomy closure (manual, device, or suture)

Understanding what is bundled is just as important as knowing what may be separately reportable.

Lesion Complexity: The Foundation of the New Code Logic

CPT® simplified complexity definitions—but their impact is significant:

• Straightforward lesion = stenosis
• Complex lesion = 100% occlusion

This distinction recognizes the added work, time, and technical skill required to treat total occlusions. Under the prior system, these differences were largely invisible. Under the new framework, they directly influence code selection and reimbursement.

The Four Vascular Territories Explained

Beginning in 2026, arteries are grouped into four distinct territories, each with its own coding hierarchy:

1. Iliac Territory (37254–37262)

• Common iliac
• External iliac
• Internal iliac

2. Common Femoral / Popliteal Territory (37263–37279)

• Common femoral / profunda femoris
• Superficial femoral / popliteal

3. Tibial / Peroneal Territory (37280–37295)

• Anterior tibial
• Posterior tibial
• Peroneal

The tibioperoneal trunk is considered part of the posterior tibial or peroneal artery unless it is the only vessel treated.

4. Inframalleolar Territory (37296–37299)

• Dorsalis pedis
• Plantar arteries

The pedal arch is not coded separately unless it is the sole vessel treated.

This territorial model is central to determining:

• Primary vs. add-on codes
• How many interventions may be reported
• Whether multiple primary codes are allowed

When Lesion Crossing Fails: What Can Still Be Reported?

If an occlusive lesion cannot be successfully crossed:

• Do not report a revascularization code
• Report diagnostic angiography and catheterization only

For Example:

Contralateral access with unsuccessful attempt to cross an anterior tibial occlusion → report 36247 and 75710 (when documentation supports medical necessity).

Separately Reportable Services: Know the Guardrails

Certain services may be reported in addition to LER codes when strict criteria are met:

Intravascular Ultrasound (IVUS)

• 37252, 37253 are separately reportable

Diagnostic Angiography

May be reported only when:

• No prior adequate study exists and the decision to intervene is based on the current study
  or
• The patient’s condition has changed
• Prior imaging was inadequate
• New findings outside the target area emerge intra-procedurally

Catheterization Codes

• Not separately reportable when performed from the same access as the intervention
• May be reported if diagnostic angiography is performed from a separate access

Thrombolysis and Mechanical Thrombectomy

• Separately reportable when performed in addition to revascularization

Primary vs. Add-On Codes: How the Hierarchy Works

Each territory allows:

• One primary code (stenosis or occlusion)
• Limited add-on codes for distinct arteries within that territory

Maximum Add-On Codes by Territory

• Iliac: up to 2
• Femoral/Popliteal: 1
• Tibial/Peroneal: up to 2
• Inframalleolar: 1

Add-on codes:

• Are never used for contiguous lesions
• May be reported with either straightforward or complex primary codes
• Represent distinct arteries, not multiple lesions in the same artery

Lithotripsy: Technology-Specific Nuances

Intravascular lithotripsy finally has dedicated CPT® recognition—but with limits:

• Iliac territory: reportable up to 3 times
• Femoral/popliteal territory: up to 2 times
• Not reportable in tibial/peroneal or inframalleolar territories

Always confirm payer-specific coverage policies, particularly Medicare guidance.

Modifier Strategy: Where Errors Commonly Occur

Key principles:

• LER codes are unilateral
• Bilateral primary procedures require modifier 50
• Add-on codes never receive modifier 50
• Use modifier 59 or XS to distinguish:
  • Different legs
  • Different territories
  • Distinct arteries

Misuse of modifiers is one of the most common audit triggers in early adoption phases.

Understanding 34717 vs. 34718: Avoiding High-Risk Errors

+34717 (Add-On Code)

• Requires a primary code from 34703–34713
• Describes placement of an iliac bifurcated endograft (IBE)
• May be used for rupture or non-rupture
• Report twice if bilateral (no modifier 50)

34718 (Primary Code)

• Stand-alone IBE placement during a separate session
• Non-rupture only
• Does not include percutaneous access or open exposure
• Bilateral procedures require modifier 50

Confusing these codes can result in significant under- or over-reporting.

Preparing for the Transition: Practical Strategies

To reduce disruption in early 2026:

• Begin joint education sessions for coders and physicians now
• Build territory-based documentation templates
• Expect and plan for temporary productivity slowdowns
• Increase internal audits and real-time feedback loops
• Develop quick-reference tools and case-based coding scenarios

Lower Extremity Revascularization (LER) 2026 Coding Checklist

A Practical Pre-Submission Reference for Coders & Compliance Teams

1. Clinical & Documentation Readiness

☐ Operative note clearly identifies each artery treated
☐ Vascular territory is explicitly stated
☐ Lesion type documented as stenosis vs. 100% occlusion
☐ Medical necessity supports the intervention
☐ Failed crossing attempts clearly documented when applicable

2. Territory Verification

☐ Iliac (common, external, internal)
☐ Common femoral / popliteal (CFA/profunda or SFA/popliteal)
☐ Tibial / peroneal (anterior tibial, posterior tibial, peroneal)
☐ Inframalleolar (dorsalis pedis, plantar)
☐ Confirm pedal arch or tibioperoneal trunk coded only when sole vessel treated

3. Primary Code Selection

☐ One primary code per territory
☐ Correct selection based on:

• ☐ Straightforward lesion (stenosis)
• ☐ Complex lesion (100% occlusion)

☐ Angioplasty coded only when it is the sole intervention

4. Add-On Code Validation

☐ Add-on codes used only for distinct arteries
☐ No add-on codes for contiguous lesions
☐ Territory-specific add-on limits verified:

• ☐ Iliac: max 2
• ☐ Femoral/popliteal: max 1
• ☐ Tibial/peroneal: max 2
• ☐ Inframalleolar: max 1

5. Lithotripsy Review (If Performed)

☐ Lithotripsy documented for calcified lesions
☐ Reported within allowed limits:

• ☐ Iliac: up to 3
• ☐ Femoral/popliteal: up to 2

☐ Not reported in tibial/peroneal or inframalleolar territories
☐ Payer coverage verified

6. Separately Reportable Services Check

☐ IVUS (37252–37253) supported and separately reportable
☐ Diagnostic angiography meets separate reporting criteria
☐ Prior imaging reviewed and documentation supports necessity
☐ Thrombolysis or mechanical thrombectomy properly supported
☐ Catheterization codes reported only when separate access used

7. Modifier Accuracy

☐ Modifier 50 applied to bilateral primary procedures only
☐ Add-on codes never reported with modifier 50
☐ Modifier 59 or XS used to distinguish:

• ☐ Different legs
• ☐ Different territories
• ☐ Distinct arteries

8. Compliance & Audit Readiness

☐ Codes align with NCCI and CPT® guidance
☐ Documentation supports all coded services
☐ Internal QA review completed
☐ High-risk cases flagged for secondary review
☐ Education feedback provided to physicians when needed

The Big Picture: Short-Term Pain, Long-Term Clarity

The 2026 lower extremity revascularization overhaul is undeniably disruptive—but it is also more logical, more precise, and better aligned with modern endovascular care than any prior system.

Practices that invest early in education, documentation alignment, and compliance oversight will not only reduce risk—they will position themselves to fully capture the value of the work they are already doing.

The goal is not just correct coding. It’s confidence, defensibility, and sustainable reimbursement in an increasingly scrutinized procedural landscape.

Turning 2026 LER Complexity Into a Controlled Advantage

The 2026 lower extremity revascularization overhaul fundamentally changes how risk, revenue, and compliance intersect. With 46 new codes, four vascular territories, stricter documentation demands, and inconsistent payer readiness, even small missteps can trigger denials, audits, or lost reimbursement.

This is where expert LER coding support becomes a risk-control strategy.

At Bristol Healthcare Services, our specialized vascular coding teams help ensure accurate territory assignment, correct lesion complexity selection, compliant modifier usage, and documentation that withstands payer and audit scrutiny. They also provide critical capacity support during the learning curve—maintaining productivity while internal teams adapt to the new framework.

Practices that act early will be better positioned to protect revenue, reduce rework, and code with confidence from day one.

Schedule a 2026 LER readiness review today, free of cost! (or) Click the link to learn more about our revenue cycle management services and medical coding services.