The 2026 Lower Extremity Revascularization Revolution: Critical Coding Concepts Unlocked for Success Part 2

As discussed last month, the lower extremity revascularization code set for occlusive disease will deliver sweeping consequences for professionals, effective January 1, 2026. The code set expanded from 16 codes to 46, with territories expanding from three to four. The volume and scope of change will leave professionals grappling with new challenges and critical questions. Preparing for the changes is the difference between swimming with the current or sinking into confusion. Part II will continue to break down the volume of change and create a more actionable understanding of the code set to fuel success in 2026.

Comprehending Complexity

Despite coders’ concerns over the overwhelming changes that the new codes bring, Laura Manser, CPC, CPCO, CDEO, CPMA, CEMC, CIRCC, RCC, states that the new LER code set has reasonable arguments for capturing the complexity and scope of modern endovascular procedures compared to the previous coding system. This overhaul will ultimately correct reimbursement shortfalls, leading to more appropriate payment for the specific work completed during a service.

“The complexity designation is huge and actually quite straightforward in definition. A straightforward lesion is a stenosis, while a complex lesion is a 100% occlusion. That’s a clear distinction that recognizes that total occlusions require significantly more work, skill, and often different techniques to cross and treat compared to stenotic lesions. Previously, you couldn’t really differentiate between these scenarios, and now you can. That should translate to more appropriate reimbursement that reflects the actual work involved.

By defining four distinct vascular territories, now including the inframalleolar territory, this update acknowledges that work below the ankle is different and often more complex.

The lithotripsy add-on codes are another good example. Intravascular lithotripsy is a newer technology that’s being used more frequently for calcified lesions, and having specific add-on codes for it means we can properly report and get paid for that additional work. The old system just wasn’t granular enough to capture modern techniques.”

Demystifying Modifiers

One key takeaway to note is that the lower extremity revascularization codes are unilateral in nature. Should bilateral primary procedures be performed, modifier 50 must be applied. If performing bilateral procedures, additional services described by add-on codes should be reported twice, with modifier 59 or XS to denote that different legs are being treated. Coders may be tempted to apply modifier 50 to these add-on codes. However, it is critical to remember that modifier 50 cannot be reported with add-on codes. When different treatments in either the same or different vascular territories are performed in either the same leg or each leg, append modifier 59 or XS to denote distinct procedures.

Dissecting Distinct Arteries and Lesions

For every territory, coding permits one primary code (straightforward or complex), along with add-on codes for additional interventions completed in the distinct arteries. This protocol is designated based on the classification and division of the arteries. So, how do we break down the coding when two distinct lesions are treated in two separate territories? In this instance, you must code two primary codes. For example, if common iliac and common femoral lesions were both treated with angioplasty, codes 37254 and 37263 would be reported. Angioplasty is only coded when it is the only intervention performed. Note that angioplasty is included in other, more intensive interventions within the same artery (i.e., stenting, atherectomy).

Analyzing Add-On Codes

Add-on codes are only used for distinct lesions treated in different vessels, not within the same vessel. If a lesion crosses from one vessel to another (contiguous) and is treated with one intervention, report only one code. The four vascular territories have differing guidelines on the number of add-on codes that may be reported:

• Iliac Territory: up to two add-on codes
  • Femoral/Popliteal Territory: one add-on code
  • Tibial/Peroneal Territory: up to two add-on codes
  • Inframalleolar Territory: one add-on code

Note that add-on codes (straightforward or complex) may be used with either complex or straightforward primary codes, according to the intervention(s) performed.

Learning Lithotripsy Guidance

Lithotripsy has some special reporting nuances that require additional attention. How many times can the procedure be reported with regard to territory?

• It may be reported up to three times for the iliac territory.
• It may be reported up to two times for the femoral/popliteal territory.

However, be aware that there are no lithotripsy codes for the tibial/peroneal or inframalleolar territories. Be certain to check and clarify Medicare payer guidelines for specific coverage limitations for this code. Under circumstances in which an additional second- or third-order vessel was selectively studied in the same vascular family, coding rules state that code 36248 must be reported for these vessels. Code 36248 is defined as an “add-on” code (denoted by the “+” sign). This code does not require modifier -59 when assigned in conjunction with codes 36245–36247. Understand that coders should not use this code pair to define placement of an arterial or venous closure device.

Stay tuned in 2026 for part three of our series to unlock even more professional tips and insights into this historical coding change sweeping the new year.

⚠️Your IR Coding Remains Under Threat, Creating Significant Risk to Your Bottom Line. These Are NOT All the Tips and Tricks Necessary for Success.⚠️

With every dollar of reimbursement counting more than ever in the face of payment decline and complex changes, it’s imperative to make sure your CPT^® coding is correct and compliant. Master more coding topics and break down the complexity with our 2026 Radiology Coding Update webcast on demand. This webcast is an essential training tool for both audio and visual learners.