2025 CPT code 37228
(Active) Effective Date: N/A Surgery - Surgical Procedures on Arteries and Veins Surgery/Cardiovascular System Feed
Endovascular, open, or percutaneous revascularization of the tibial or peroneal artery, unilateral, initial vessel; with transluminal angioplasty.
Modifiers may be applicable.For example, modifier 52 could indicate reduced services if the procedure was discontinued prematurely. Modifier 59 might be used to indicate a distinct procedural service.
Medical necessity for this procedure is established by demonstrating impaired blood flow in the tibial or peroneal artery causing symptoms like claudication, rest pain, non-healing ulcers, or gangrene. Diagnostic tests like angiography or Doppler ultrasound are usually required to confirm the diagnosis and the severity of the blockage. The medical record should clearly document the patient's symptoms and the link between the blockage and the clinical presentation.
The physician selects the appropriate approach (endovascular, open, or percutaneous) based on the patient's condition and the location of the blockage.They insert and guide the catheter to the occlusion site, inflate the balloon, and confirm successful revascularization using imaging guidance. Post-procedure care, such as applying a compression bandage or suturing the incision, is also the physician's responsibility.
In simple words: This procedure opens up blocked blood vessels in the lower leg to restore blood flow. A tiny balloon is inserted into the artery and inflated to widen the narrowed area, improving circulation.
This procedure involves restoring blood supply to the tibial or peroneal artery using transluminal angioplasty.A balloon catheter is inserted into the affected artery and inflated to expand the narrowed or blocked area, restoring blood flow.This can be done through an endovascular, open, or percutaneous approach. This code applies to the initial vessel treated.
Example 1: A patient presents with critical limb ischemia and a non-healing ulcer on their lower leg due to a blocked tibial artery. Angiography confirms the diagnosis, and the physician performs an endovascular revascularization with transluminal angioplasty using code 37228., A patient with peripheral artery disease experiences severe claudication in their calf during exercise due to stenosis in the peroneal artery.The physician performs a percutaneous transluminal angioplasty to restore blood flow, using code 37228., A diabetic patient develops a blockage in their tibial artery, leading to rest pain in their foot. The physician performs an open revascularization with transluminal angioplasty to improve circulation and prevent further complications. Code 37228 is used.
Documentation should include details of the patient's symptoms, diagnostic angiography results, the chosen approach (endovascular, open, or percutaneous), the location of the blockage, the size and type of balloon catheter used, and confirmation of successful revascularization. Any complications encountered during or after the procedure must also be documented.
- Revenue Code: P2F
- Payment Status: Active
- Modifier TC rule: Not applicable
- Specialties:Interventional Radiology, Vascular Surgery, Cardiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center