The 2026 Lower Extremity Revascularization Revolution: Critical Coding Concepts Unlocked for Success Part 3

2026 has arrived, and for many coding professionals, the lower extremity revascularization overhaul is quickly shifting from a future concern in 2025 to a day-to-day reality in the new year. True success will depend on understanding how those changes play out in real clinical cases. Experts stress that the new framework brings welcome clarity, but only for organizations that take the time to master its nuances. Building on the insights from Parts 1 and 2, this third installment offers additional expert commentary to foster success while analyzing the critical distinctions between codes 34717 and 34718.

Transition Challenges

Ultimately, numerous challenges will present themselves as professionals dive into the new code set. Subject matter expert Laura Manser, CPC, CPCO, CDEO, CPMA, CEMC, CIRCC, RCC expects that the transition period will be rough, stating, “Coders who have been using the same 15 codes for years will instinctively reach for those old codes, but they’re deleted. That’s going to require retraining and probably some job aids or quick reference guides to bridge that gap. For providers, the initial documentation burden increases. They need to be more specific, more detailed, and more structured in how they describe these procedures. Some physicians are going to push back on that because it takes more time.” She also stresses that education remains imperative going into the start of 2026. “To prepare, organizations should start now with education. Bring coders and physicians together for training sessions. Walk through case examples using the new code set. Create coding scenarios and have people practice. Also, plan for your coding production to slow down initially. If you normally code 50 charts a day, you might only get through 30 while people are learning. Budget for that.”

The overhaul will have multiple impacts across the board. As Manser states, “The shift to outpatient settings is part of a broader CMS strategy, and it has multiple implications. From a reimbursement standpoint, outpatient rates are typically different than inpatient rates, and with the site-of-service differential that CMS finalized, there’s pressure to move more procedures outpatient. That can impact the bottom line depending on your setting and payer mix.

Documentation becomes even more critical in the outpatient world because you don’t have the same level of infrastructure and support. Medical necessity documentation needs to be airtight. You need to show why this procedure is appropriate and that the patient is an appropriate candidate.

For compliance, there’s increased scrutiny on outpatient procedures, not to mention these revascularization procedures were already on the OIG worklist. Are you meeting medical necessity criteria? Are you properly documenting the decision-making process? With 46 new codes, auditors are going to be looking closely to make sure the correct codes are being used and that documentation supports them. Organizations need robust compliance monitoring programs, regular audits of their own coding, and feedback loops to physicians when documentation is inadequate.”

The Peak of Change

With such a vast overhaul, it can be helpful to identify the most important changes and grasp a clearer understanding of the big picture. According to Manser, “The biggest change is the expansion to four vascular territories with the addition of the inframalleolar territory, which recognizes that work below the ankle is distinct and often more complex. The new add-on code structure creates a clearer hierarchy that differentiates between simple lesions (stenosis) and complex lesions (100% occlusion), allowing practices to accurately capture the additional work involved in total occlusions.

Lithotripsy now has dedicated add-on CPT codes, which is significant because this technology is being used more frequently for calcified lesions and previously couldn’t be properly reported. Finally, there’s clearer modifier guidance for bilateral procedures, which eliminates previous ambiguity about how to report work done on both legs. Overall, the new structure is more granular, better reflects modern endovascular techniques, and provides a logical framework that should reduce confusion once people get over the learning curve.”

Breaking Down 34717 vs. 34718

In addition to expert commentary, our series will again offer some exclusive insider professional tips related to the coding changes.  Code +34717 encompasses an add-on service and must be assigned with a primary code from the 34703–34713 series. More specifically, code +34717 defines placement of an iliac bifurcated endograft (IBE). This graft extends from the common iliac artery into the internal and external iliac arteries, as well as the common femoral artery. This code may be assigned when the IBE is placed for reasons of rupture or non-rupture. How does the treatment zone play a role in code assignment? The zone for this code (as well as 34718 and 34708) is defined as the portion of the iliac artery(ies) that contains the endograft.

As this is a multi-piece system (think of an inverted letter “Y”), any extensions placed that extend into the aorto-iliac portion of the initial graft, or into the internal or external iliac artery(ies) or common femoral artery(ies), are not separately coded. Codes 34709, 34710, or 34711 (ipsilaterally) may not be reported with code 34717 (or 34718); however, these codes may be reported when performed bilaterally. As 34717 is an add-on code, if performed bilaterally, assign this code twice—not once with modifier 50.

Code 34718 defines a primary service. However, there are important components that this code does not include and that may result in inaccurate coding if not recognized. This code does not include percutaneous access and placement of a closure device (12F sheath or larger), or open exposure (34713, 34812, 34820, 34834). On the upside, this code does include all ipsilateral non-selective or selective catheter placements.

Our experts remind coders that, clinically, this occurs when an iliac bifurcated endograft (IBE) is placed during a different session than the initial placement of the abdominal aortic endograft. Unlike code +34717, which may be used to define placement of an IBE for non-rupture or rupture, code 34718 is exclusively reported when an IBE is placed for non-rupture situations. If a stand-alone IBE is placed for rupture, assign unlisted procedure code 37799.

There are some key clinical components to note when working with this code:

• This graft extends from the common iliac artery into the internal and external iliac arteries, as well as the common femoral artery.
• The treatment zone for this code (as well as +34717, 34707, and 34708) is defined as the portion of the iliac artery(ies) that contains the endograft.
• As this is a multi-piece system (think of an inverted letter “Y”), any extensions placed that extend into the aorto-iliac portion of the initial graft, or into the internal or external iliac artery(ies) or common femoral artery(ies), are not separately coded.

Finally, note that codes 34709, 34710, or 34711 (ipsilaterally) may not be reported with code 34718 (or +34717); however, these codes may be reported when performed bilaterally. As this is a primary code, if performed bilaterally, assign this code with modifier 50.

Final Thoughts on the Future

With the volume of change, far more challenges and nuances exist than can be addressed here. Further education will be imperative for professionals and teams to tackle the 2026 coding overhaul correctly and increase their chances of success. However, Manser offers some final thoughts and takeaways on what to expect this year. First, foolproof compliance will be imperative heading into 2026. “Compliance programs need to be on high alert. With new codes come new audit targets. You need to be doing regular internal audits to catch errors before payers do. You need education programs not just at rollout, but ongoing throughout 2026. And you need clear policies about how to handle gray areas or uncertain documentation,” states Manser.

 Coders will face fast and immediate learning curve challenges, as Manser reveals: “From a coding perspective, expect slower productivity initially, more queries back to physicians for clarification, and probably an uptick in coding errors as people learn. You’ll need more quality assurance and potentially more coding staff or overtime during the transition. Coders are nervous. Change is always hard, and this is a big change. But many recognize that once they get over the learning curve, the new structure might actually be clearer and more logical than the old system. It’s a short-term pain for potential long-term gain.”

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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 IR Masterclass: Basics of Interventional Radiology Coding webcast on January 14, 2026 at 11:00 am CT (120 minutes). This webcast is an essential training tool for both audio and visual learners.