Peripheral vascular interventions—such as angioplasty, atherectomy, thrombectomy, and stent placement—are among the most complex and scrutinized areas of cardiovascular billing. Unlike coronary interventions, which revolve around a three-vessel system, peripheral interventions use territory-based coding rules, bundling structures, and multiple add-on codes. Proper documentation is essential to prevent denials, especially in cases involving multi-level or multi-vessel procedures.
This guide provides a detailed, structured, and technical explanation of PVI coding, documentation expectations, anatomic rules, modifiers, payer-specific considerations, and frequent errors.
Understanding the Foundation: Arterial Territories in PVI
PVI CPT coding is determined by identifying the vascular territory in which the work is performed. Each limb has three main vascular territories, and each territory can include multiple vessels and levels:
1. Iliac Territory
- Common iliac
- External iliac
- Internal iliac
2. Femoral–Popliteal Territory
- Common femoral
- Superficial femoral (SFA)
- Popliteal artery
All of these are one contiguous territory for coding.
3. Tibial–Peroneal Territory
- Anterior tibial
- Posterior tibial
- Peroneal artery
- Tibioperoneal trunk
Each of these may have separate interventions but fall under the same general tibial–peroneal category depending on the type of service.
Understanding territories is essential because CPT codes allow one “initial” intervention per territory and subsequently allow add-on codes for additional distinct vessels within that territory.
Major Types of PVI Procedures
Peripheral interventions fall into several categories:
- Transluminal balloon angioplasty
- Stent placement
- Atherectomy (directional, orbital, laser)
- Thrombectomy
- Thrombolysis
- Embolectomy
- Mechanical recanalization
Different CPT codes—and different bundling rules—apply for each category.
Iliac Artery Intervention Codes (37220–37223)
The iliac territory uses the following structure:
37220 – Iliac angioplasty, initial vessel
37221 – Iliac stent placement, initial vessel
37222 – Iliac angioplasty, each additional vessel (add-on)
37223 – Iliac stent placement, each additional vessel (add-on)
Key rules:
- Stent placement includes angioplasty in the same iliac vessel.
- If both angioplasty and stent occur in the same vessel, bill only the stent code (37221).
- If a different iliac vessel requires angioplasty only, bill 37222.
Documentation must specify:
- Which iliac vessels were treated
- Whether procedures were in separate vessels or the same vessel
- Interventions done in sequence (e.g., angioplasty → stent)
Femoral–Popliteal Intervention Codes (37224–37227)
These represent the most common and audited PVI codes.
37224 – Fem-pop angioplasty (initial)
37225 – Fem-pop atherectomy (includes angioplasty)
37226 – Fem-pop stent placement (includes angioplasty)
37227 – Atherectomy + stent (includes angioplasty)
Bundling rules:
- Stent includes angioplasty.
- Atherectomy includes angioplasty.
- If atherectomy + stent occurs in the same vessel, use 37227.
- If atherectomy in SFA and a stent in the popliteal, this may qualify as add-on coding depending on vessel-level definitions; documentation must be precise.
Tibial–Peroneal Intervention Codes (37228–37235)
These codes cover below-the-knee interventions.
37228 – Tibial/peroneal angioplasty, initial vessel
37229 – Angioplasty, each additional tibial/peroneal vessel (add-on)
37230 – Tibial/peroneal atherectomy (initial, includes angioplasty)
37231 – Atherectomy, each additional tibial/peroneal vessel
37232 – Stent placement (initial)
37233 – Stent, each additional vessel
37234 – Atherectomy + stent (initial)
37235 – Atherectomy + stent, each additional vessel
Key concept:
The tibial–peroneal territory allows multiple add-on codes because multiple separate arteries may be diseased and treated (AT, PT, Peroneal, TP trunk).
Documentation must reflect:
- Distinct lesions
- Distinct vessels
- Techniques used (atherectomy vs stent vs PTA)
Additional Peripheral Interventions
Mechanical Thrombectomy
- 37184–37186 depending on vessel count and technique
- Frequently used for acute limb ischemia or a large clot burden.
Catheter-Directed Thrombolysis
- 37211–37214, depending on duration and intensity
- Requires documentation of infusion duration, drug, dosage, and monitoring.
Embolectomy
- 34201–34203 (open)
- 37184 (percutaneous)
These have very strict definitions and bundling rules.
Diagnostic Angiography & Catheterization
Diagnostic imaging (75710–75716, 36245–36248) can only be billed if:
- No prior angiographic study exists, or
- A change in patient condition warrants repeat imaging, and
- The decision to intervene was not made prior to the angiogram.
Otherwise, it is considered bundled.
Catheter Placement Codes Common in PVI
- 36245 – First-order
- 36246 – Second-order
- 36247 – Third-order
- 36248 – Additional fourth-order
- These are billable only when meeting the diagnostic criteria above.
Imaging Codes
- 75710 – Unilateral extremity
- 75716 – Bilateral extremity
Documentation must clearly state that imaging was diagnostic, interpreted, and influenced procedural decision-making.
Modifiers in PVI Billing
59 or XS
Used when interventions are in separate, distinct vessels within the same limb.
RT / LT
Required by many payers for laterality.
26 / TC
For diagnostic imaging and S&I components.
52 / 53
Used when procedures are reduced or discontinued.
76 / 77
Repeat PVI procedures on the same day by the same/different provider—rare but possible.
XP
Used when different physicians perform distinct components (varies by payer).
Incorrect or missing modifiers are a leading cause of PVI denials.
Documentation Requirements
Patients expect precise anatomic and procedural detail. Every PVI operative report should include:
1. Clinical Indication
- Claudication
- Critical limb ischemia
- Rest pain
- Tissue loss
- Nonhealing ulcers
- Objective evidence (ABI, TBI, duplex findings)
2. Vessels Accessed
- Access site
- Catheter course
- Vessels selectively catheterized
3. Diagnostic Imaging Findings
Required to justify separate diagnostic angiography.
4. Interventions Performed
Must include:
- Vessel name
- Vessel segment (proximal, mid, distal)
- Lesion characteristics (stenosis %, length, calcification)
- Device used (balloon, stent type, atherectomy type, thrombectomy device)
- Technique (predilation, postdilation)
5. Outcomes
- Final residual stenosis
- Flow restoration
- Complications (dissection, perforation, thrombosis)
6. Fluoroscopy Time & Contrast
Often required for audit validation.
Payer-Specific Considerations
Medicare
- Strict with diagnostic criteria
- Heavy scrutiny of add-on codes (especially tibial–peroneal)
- Global rules apply to any open surgical components
Commercial Payers
Often require:
- Prior authorization for PVI
- Documentation of failed conservative therapy
- Imaging evidence (ABI/Duplex) prior to intervention
Medicaid
Requirements vary by state, often mirroring Medicare but with more prior authorization steps
Global Surgical Periods
Most percutaneous vascular interventions have 0-day global periods.
However, any open peripheral surgical procedures may have 90-day global periods.
This affects:
- Same-day E/M services (modifier 25)
- Return procedures (modifier 78 for complications)
Common Denials & How to Prevent Them
1. Unclear Vessel Documentation
Solution: Clearly identify vessel, segment, and territory.
2. Incorrect Code Levels (Initial vs Add-On)
Solution: Identify the initial vessel in each territory before selecting add-ons.
3. Bundling Denials for Diagnostics
Solution: Justify diagnostic angiography with proper clinical documentation.
4. Inappropriate Use of Modifier 59
Solution: Use XS (separate structure) when possible; do not unbundle within the same vessel.
5. Lack of Prior Authorization
Solution: Review payer-specific PVI policies; maintain authorization logs.
6. “Too Many Add-On Codes” Audit Flags
Solution: Ensure documentation supports multiple distinct vessels.
7. Missing Fluoroscopy or Contrast Documentation
Solution: Include fluoroscopy time and contrast volume in every case.
Conclusion
Peripheral vascular intervention billing requires a detailed understanding of arterial territories, CPT bundling rules, modifier choices, and diagnostic angiography criteria. High-quality documentation—covering vessel anatomy, lesion specifics, procedural sequence, and imaging interpretation—is essential for accuracy and compliance. Because PVI coding involves numerous add-on codes and payer-specific nuances, coders benefit from standardized templates and internal review processes. Practices seeking consistent, compliant vascular billing and documentation workflows often partner with experienced cardiology-focused RCM organizations such as Global Tech Billing LLC.
FAQs
1. How are peripheral vascular territories defined for billing?
Each limb has three territories: iliac, femoral–popliteal, and tibial–peroneal. One initial code applies per territory.
2. Does stent placement include angioplasty?
Yes. In all PVI territories, stent placement includes angioplasty in the same vessel.
3. When can diagnostic angiography be billed?
Only when it is medically necessary, not recently performed, and the decision to intervene was not made beforehand.
4. Are multiple tibial interventions billable?
Yes, each distinct tibial/peroneal vessel treated may qualify for add-on codes.
5. What modifiers are commonly used in PVI?
26, TC, RT/LT, 59, XS, XP, 52, 53, 76, 77, depending on scenario.
6. What documentation is required for PVI?
Clinical indication, diagnostic findings, vessel treated, lesion details, procedural steps, and outcomes.
7. Do PVIs have global periods?
Most percutaneous PVIs have a 0-day global period.
8. Why do PVI claims get denied most often?
Insufficient vessel-level documentation, lack of medical necessity, incorrect add-on code usage, or missing prior authorization.
