37226

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

CPT code 37226 describes an endovascular revascularization procedure performed on the femoral and/or popliteal arteries of a single lower extremity, specifically involving the placement of one or more transluminal stents. This code comprehensively includes any percutaneous transluminal angioplasty performed within the same vessel territory during the same operative session. The femoral-popliteal segment is a common site for atherosclerotic plaque accumulation, leading to Peripheral Artery Disease. Patients typically present with life-limiting intermittent claudication, ischemic rest pain, or severe tissue loss such as non-healing ulcers or gangrene. The procedure is typically performed under local anesthesia and conscious sedation. Vascular access is most commonly obtained via the common femoral artery, either through an ipsilateral antegrade approach or a contralateral retrograde approach over the aortic bifurcation. Once access is established and a vascular sheath is in place, the physician administers systemic anticoagulation. Utilizing continuous fluoroscopic guidance, a guidewire and catheter are navigated across the stenotic or occlusive lesion within the superficial femoral artery or popliteal artery. If the lesion is highly calcified or tightly stenosed, pre-dilation with an angioplasty balloon may be performed to facilitate stent delivery. Subsequently, a stent delivery system is advanced to the target site. The stent, which may be bare-metal, drug-eluting, or covered, is meticulously deployed across the lesion to mechanically scaffold the vessel wall and restore luminal patency. Following deployment, post-dilation with a balloon catheter is frequently executed to ensure optimal stent expansion and apposition to the arterial wall. A completion angiogram is then performed to confirm the restoration of antegrade blood flow and to rule out any procedural complications such as distal embolization, flow-limiting dissections, or vessel rupture. Finally, the delivery systems and sheath are removed, and hemostasis is achieved using manual compression or a specialized percutaneous closure device. It is crucial to note that for coding purposes, the entire femoral and popliteal arterial system in one leg is considered a single vascular territory. Therefore, regardless of whether stents are placed in multiple lesions across both the superficial femoral and popliteal arteries of the same limb, CPT code 37226 is reported only once. All associated radiological supervision, interpretation, and intra-procedural roadmapping are inherently bundled into this code.

Clinical Indications

  • Severe, lifestyle-limiting intermittent claudication unresponsive to conservative medical therapy and exercise.
  • Critical limb ischemia characterized by ischemic rest pain.
  • Presence of non-healing ischemic ulcers or focal gangrene on the affected lower extremity.
  • Flow-limiting dissection or suboptimal result following balloon angioplasty of the femoral or popliteal artery.
  • Significant hemodynamically limiting stenosis or complete occlusion of the superficial femoral artery or popliteal artery.
  • In-stent restenosis of a previously deployed stent in the femoropopliteal segment requiring re-stenting.

Procedure Steps

  1. Patient is positioned appropriately, prepped, and draped in a sterile fashion; local anesthesia and conscious sedation are administered.
  2. Percutaneous access is obtained, typically via the common femoral artery (ipsilateral or contralateral), and a vascular sheath is placed.
  3. Systemic anticoagulation, such as heparin, is administered to prevent thrombosis during the intervention.
  4. Diagnostic angiography is performed if not previously completed to precisely map the lesion and vascular anatomy.
  5. Under continuous fluoroscopic guidance, a specialized guidewire is navigated across the target lesion in the superficial femoral or popliteal artery.
  6. If necessary, pre-dilation of the stenotic or occlusive lesion is performed using an angioplasty balloon catheter.
  7. The stent delivery system is introduced over the guidewire and positioned accurately across the lesion.
  8. The stent is deployed to scaffold the vessel open, and post-dilation with a balloon may be performed to ensure full expansion and wall apposition.
  9. Completion angiography is conducted to verify restored blood flow, proper stent placement, and absence of procedural complications.
  10. The delivery system, guidewire, and sheath are removed, and hemostasis is secured via manual compression or a vascular closure device.

Coding Guidelines

  • Do not report 37226 in conjunction with 37224 (angioplasty) for the same vessel territory; angioplasty is inherently bundled.
  • The femoral and popliteal arteries are treated as a single vessel territory for coding. Report 37226 only once per leg, regardless of the number of stents placed or lesions treated in the superficial femoral and popliteal arteries.
  • If atherectomy is performed in addition to stent placement within the same femoropopliteal territory, report 37227 instead of 37226.
  • Diagnostic angiography may be reported separately only if it is a true diagnostic study determining the need for intervention, or if evaluating a completely separate vascular territory. Use appropriate modifiers (e.g., 59 or XU) if supported by documentation.
  • Fluoroscopic guidance, radiological supervision and interpretation, and intra-procedural roadmapping are bundled; do not report separately.
  • If the procedure is performed bilaterally, append modifier 50 or report twice with RT and LT modifiers depending on specific payer requirements.
  • Do not separately report the use of a vascular closure device; this is included in the base procedure code.

Associated ICD-10 Codes