LCD Reference Article Billing and Coding Article

Billing and Coding: Non-Coronary Vascular Stents

A57590

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A57590
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Non-Coronary Vascular Stents
Article Type
Billing and Coding
Original Effective Date
11/01/2019
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

CMS Pub. 100-03 Medicare National Coverage Determination (NCD) Manual, Chapter 1-Coverage Determinations, Part 1, Section 20.7-Percutaneous Transluminal Angioplasty
National Coverage Analysis (NCA) for Percutaneous Transluminal Angioplasty (PTA) and Stenting of the Renal Arteries (CAG-00085R4)
CMS Pub. 100-08 Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, Section 13.5 - Content of an LCD and Section 13.5.1-Reasonable and Necessary Provisions in LCDs

Social Security Act (Title XVIII) Sections:
1862 (a)(1)(A) Medically Reasonable & Necessary
1862 (a)(1)(D) Investigational or Experimental
1862 (a)(7) Screening (Routine Physical Checkups)

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(12 Codes)
Group 1 Paragraph

Note: The CPT codes 37236, 37237, 37238, and 37239 are used to report stenting of multiple anatomically defined arteries or veins. Therefore, provisions of this policy apply as appropriate to the procedure performed and reported on the Medicare claim.

Group 1 Codes
Code Description
37221 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
37223 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37226 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
37227 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
37230 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
37231 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
37234 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37235 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37236 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY
37237 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37238 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN
37239 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(7 Codes)
Group 1 Paragraph

CPT/HCPCS codes 37236 and 37237:
Covered for:

Brachiocephalic arteries (including subclavian, except carotid bifurcation):

Group 1 Codes
Code Description
G45.8 Other transient cerebral ischemic attacks and related syndromes
I70.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity
I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I72.1 Aneurysm of artery of upper extremity
I74.2 Embolism and thrombosis of arteries of the upper extremities

Group 2

(2 Codes)
Group 2 Paragraph

CPT/HCPCS codes 37236 and 37237:
Covered for:

Pulmonary artery:

Group 2 Codes
Code Description
Q25.5 Atresia of pulmonary artery
Q25.71 Coarctation of pulmonary artery

Group 3

(16 Codes)
Group 3 Paragraph

CPT/HCPCS codes 37236, 37237, 37238, and 37239:
Covered for:

Hemodialysis access graft/fistula:

The following codes must include the proper 7th digit: (A-initial encounter; D-subsequent encounter; S-sequela).

Group 3 Codes
Code Description
T80.818A Extravasation of other vesicant agent, initial encounter
T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter
T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter
T82.520A Displacement of surgically created arteriovenous fistula, initial encounter
T82.521A Displacement of surgically created arteriovenous shunt, initial encounter
T82.530A Leakage of surgically created arteriovenous fistula, initial encounter
T82.531A Leakage of surgically created arteriovenous shunt, initial encounter
T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter
T82.591A Other mechanical complication of surgically created arteriovenous shunt, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter
T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter
T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter

Group 4

(21 Codes)
Group 4 Paragraph

CPT/HCPCS codes 37236, 37237, 37238, and 37239:
Covered for:

Mesenteric vessels:

Group 4 Codes
Code Description
K55.011 Focal (segmental) acute (reversible) ischemia of small intestine
K55.012 Diffuse acute (reversible) ischemia of small intestine
K55.019 Acute (reversible) ischemia of small intestine, extent unspecified
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.029 Acute infarction of small intestine, extent unspecified
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.039 Acute (reversible) ischemia of large intestine, extent unspecified
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.049 Acute infarction of large intestine, extent unspecified
K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified
K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified
K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified
K55.061 Focal (segmental) acute infarction of intestine, part unspecified
K55.062 Diffuse acute infarction of intestine, part unspecified
K55.069 Acute infarction of intestine, part and extent unspecified
K55.1 Chronic vascular disorders of intestine
K55.8 Other vascular disorders of intestine
K55.9 Vascular disorder of intestine, unspecified

Group 5

(31 Codes)
Group 5 Paragraph

CPT/HCPCS codes 37238 and 37239:
Covered for:

Venous:

The following code (T66.XXX) must include the proper 7th digit: (A-initial encounter; D-subsequent encounter; S-sequela).

Group 5 Codes
Code Description
I80.11 Phlebitis and thrombophlebitis of right femoral vein
I80.12 Phlebitis and thrombophlebitis of left femoral vein
I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.211 Phlebitis and thrombophlebitis of right iliac vein
I80.212 Phlebitis and thrombophlebitis of left iliac vein
I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral
I80.8 Phlebitis and thrombophlebitis of other sites
I82.210 Acute embolism and thrombosis of superior vena cava
I82.220 Acute embolism and thrombosis of inferior vena cava
I82.221 Chronic embolism and thrombosis of inferior vena cava
I82.290 Acute embolism and thrombosis of other thoracic veins
I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity
I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity
I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral
I82.411 Acute embolism and thrombosis of right femoral vein
I82.412 Acute embolism and thrombosis of left femoral vein
I82.413 Acute embolism and thrombosis of femoral vein, bilateral
I82.421 Acute embolism and thrombosis of right iliac vein
I82.422 Acute embolism and thrombosis of left iliac vein
I82.423 Acute embolism and thrombosis of iliac vein, bilateral
I82.A11 Acute embolism and thrombosis of right axillary vein
I82.A12 Acute embolism and thrombosis of left axillary vein
I82.A13 Acute embolism and thrombosis of axillary vein, bilateral
I82.B11 Acute embolism and thrombosis of right subclavian vein
I82.B12 Acute embolism and thrombosis of left subclavian vein
I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral
I87.1 Compression of vein
Q26.0 Congenital stenosis of vena cava
Q26.1 Persistent left superior vena cava
Q26.8 Other congenital malformations of great veins
T66.XXXA Radiation sickness, unspecified, initial encounter

Group 6

(11 Codes)
Group 6 Paragraph

CPT/HCPCS codes 37236 and 37237:
Covered for:


Renal Artery:

Group 6 Codes
Code Description
I72.2 Aneurysm of renal artery
I75.81 Atheroembolism of kidney
I77.73 Dissection of renal artery
Q27.1 Congenital renal artery stenosis
Q27.2 Other congenital malformations of renal artery
Q27.34 Arteriovenous malformation of renal vessel
T86.10 Unspecified complication of kidney transplant
T86.11 Kidney transplant rejection
T86.12 Kidney transplant failure
T86.13 Kidney transplant infection
T86.19 Other complication of kidney transplant

Group 7

(2 Codes)
Group 7 Paragraph

dual diagnosis (two covered diagnoses) requirement for CPT/HCPCS codes 37236 and 37237:
Covered for:


Renal Artery:

Group 7 Codes
Code Description
I70.1* Atherosclerosis of renal artery
I77.3* Arterial fibromuscular dysplasia
Group 7 Medical Necessity ICD-10-CM Codes Asterisk Explanation

**Note: Additional diagnosis from table below required for coverage of renal artery stenting.

Group 8

(12 Codes)
Group 8 Paragraph

CPT/HCPCS codes 37236 and 37237:
Covered for:


Renal Artery:

Additionally required diagnosis code to be used with I70.1 and I77.3 to meet limited coverage for CPT/HCPCS 37236 and 37237 must be one from the list below:

Group 8 Codes
Code Description
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I15.0 Renovascular hypertension
I15.1 Hypertension secondary to other renal disorders
J81.0 Acute pulmonary edema
N17.8 Other acute kidney failure
N17.9 Acute kidney failure, unspecified
N26.2 Page kidney

Group 9

(184 Codes)
Group 9 Paragraph

CPT/HCPCS codes 37221, 37223, 37226, 37227, 37230, 37231, 37234, 37235, 37236 and 37237:
Covered for:


Lower extremity arteries:The following code (T82.858X) must include the proper 7th digit: (A-initial encounter; D-subsequent encounter; S-sequela).

Group 9 Codes
Code Description
E10.59 Type 1 diabetes mellitus with other circulatory complications
E11.59 Type 2 diabetes mellitus with other circulatory complications
E13.59 Other specified diabetes mellitus with other circulatory complications
I70.0 Atherosclerosis of aorta
I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg
I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs
I70.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity
I70.219 Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity
I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg
I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs
I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity
I70.231 - I70.238 Atherosclerosis of native arteries of right leg with ulceration of thigh - Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg
I70.241 - I70.248 Atherosclerosis of native arteries of left leg with ulceration of thigh - Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I70.301 - I70.303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs
I70.311 - I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.321 - I70.323 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, bilateral legs
I70.331 - I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.341 - I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.361 - I70.363 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs
I70.401 - I70.403 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs
I70.411 - I70.413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.421 - I70.423 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, bilateral legs
I70.431 - I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.441 - I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.461 - I70.463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, bilateral legs
I70.491 - I70.493 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg - Other atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs
I70.501 - I70.503 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs
I70.511 - I70.513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.521 - I70.523 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, bilateral legs
I70.531 - I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.541 - I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.561 - I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, bilateral legs
I70.591 - I70.593 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg - Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs
I70.601 - I70.603 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs
I70.611 - I70.613 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.621 - I70.623 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, bilateral legs
I70.631 - I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.641 - I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.661 - I70.663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, bilateral legs
I70.691 - I70.693 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg - Other atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs
I70.701 - I70.703 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs
I70.711 - I70.713 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.721 - I70.723 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, bilateral legs
I70.731 - I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.741 - I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg
I70.761 - I70.763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, bilateral legs
I70.791 - I70.793 Other atherosclerosis of other type of bypass graft(s) of the extremities, right leg - Other atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs
I71.010 Dissection of ascending aorta
I71.011 Dissection of aortic arch
I71.012 Dissection of descending thoracic aorta
I71.02 Dissection of abdominal aorta
I71.31 Pararenal abdominal aortic aneurysm, ruptured
I71.32 Juxtarenal abdominal aortic aneurysm, ruptured
I71.33 Infrarenal abdominal aortic aneurysm, ruptured
I71.41 Pararenal abdominal aortic aneurysm, without rupture
I71.42 Juxtarenal abdominal aortic aneurysm, without rupture
I71.43 Infrarenal abdominal aortic aneurysm, without rupture
I72.3 Aneurysm of iliac artery
I72.4 Aneurysm of artery of lower extremity
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
I74.8 Embolism and thrombosis of other arteries
I77.72 Dissection of iliac artery
I77.73 Dissection of renal artery
Q25.21 Interruption of aortic arch
Q25.29 Other atresia of aorta
Q25.3 Supravalvular aortic stenosis
T80.818A Extravasation of other vesicant agent, initial encounter
T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R3

Posted 08/31/2023 Under ICD-10-CM Codes that Support Medical Necessity Group 3 & 9 added T80.818A at the request of a provider. Review completed 07/18/2023.

10/01/2022 R2

Posted 09/29/2022 Under ICD-10-CM Codes that Support Medical Necessity Group 9 Codes the following codes were added: I71.010, I71.011, I71.012, I71.31, I71.32, I71.33, I71.41, I71.42, and I71.43. The following codes were deleted: I71.3 and I71.4. These updates were made due to the annual ICD-10-CM code update and are effective 10/01/2022.

10/28/2021 R1

10/28/2021 Review completed 10/04/2021.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
NCDs
20.7 - Percutaneous Transluminal Angioplasty (PTA)
SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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