Chapters Transcript Video 2026 Lower Extremity Revascularization Coding Change Good evening everyone. My name is Ben Barclay, and I'm here. I'm the senior director of our health economic team at peripheral Intervention and I'm here with my colleague and friend Dion Chen who's a senior manager with our team as well. And tonight we're going to spend a few minutes, tonight we're gonna go to take a few minutes and go over some of the significant changes that are happening with coding and reimbursement for, uh, lower extremity arterial revascularizations. Just a quick disclaimer that the information that we're sharing with you tonight comes directly from the AMA CPT, uh, code book and so there as we share this, just keep in mind that we're not guaranteeing any particular coverage level or payment level. We're gonna share with you some national payment averages, but that is very specific to your locality and and hospital type and things like that as well and contracts so. We'll jump right into this, um, for those who are aware or maybe not aware in 2025 we had 16 CPT codes and that has changed drastically to 46 CPT codes for for lower extremity arterial revascularization. Um, we still retain the same vascular territories in that we have the iliac. Femoral and and popliteal as well as infrapopliteal, but what is new for 2026 is this new group called the inframalleolar. And uh we'll talk a little bit about uh why they've done that and and what's going on there. It's important to note that the CPT codes that we share with you tonight represent both percutaneous and open procedures. It also includes all maneuvers necessary to, you know, selectively catheterize the artery, cross the lesion, perform the intervention. In addition to that, it includes intraprocedural, uh, imaging and radiological supervision and interpretation. And then lastly, um, it also this the amounts that we'll show you, uh, the with the CPT codes include embolic protection and, uh, closure of the arteriotomy. So jumping right into it, the big change for 2026 is that the AMA has differentiated between straightforward lesions and complex lesions. We get a lot of questions on this, and so I wanna be very clear. A straightforward lesion is a stenosis that ranges anywhere from 1% to 99%, and that is a straightforward lesion. A an occlusion or a complex lesion is a 100% occluded vessel. That means when you shoot the contrast you don't see any going through. If you see any contrast going through there at all, then that is defined as a straightforward lesion. So there's been a lot of questions. People like, what if it's 98% and this and that? No, if it's 98%, it's straightforward. If it's 100%, it's completely occluded. It's, it's complex. Now what they've also done is they've created add-on codes for each of the vascular territories. You'll see that in iliac, femoral, uh popliteal, infrapopliteal, and inframlleolar, and each of these vascular territories has a base code or a primary code with add-ons. And, and, and keep in mind that every vascular territory is treated as a new area. And we'll get into specifics and then lastly if you have a lesion that extends let's say through one vascular territory into the next vascular territory you should code using the most distal vascular territory so a great example. You've got a continuous lesion that extends from the popliteal through the tibial perineal trunk into you know the infrapopliteal region or vascular territory that would be coded as a infrapopliteal lesion and it's as one lesion if it's one continuous lesion. All right, so jumping right into iliac, you can see on the left there we've got the primary or base codes, and then on the right we've got the add-on codes. An important thing to note with the iliac vascular territory is that AMA has defined this as having three distinct vascular beds, uh, uh, um, the common iliac, the internal and external, and. When you code, you define one of those three as your primary, uh, stenosis is treated and let's say you had a stenosis in each one of those you could code for each one of those that you would determine which one was the most. Complex and that would be your primary base code and then each subsequent vascular bed would be an add-on code. So let's say the most complex is the external you'd code that as your primary and then internal common would be add-on codes and uh so what that really means is you have a a base and two add-ons for that. And then when it goes to lithotripsy because lithotripsy is an add-on, you have opportunity up to 3 add-on. Uh, codes in that vascular territory. So in this next area, the Fem pop territory, there's been a big change from 25 to 26. So previously there was no add-on codes available in this vascular territory and it's actually been split into two, so you two territories. So you have your common femoral and your profunda, which is one territory, and then you have your SFA and your popliteal considered to be a second territory. So with the add-on codes now you have that base code like Ben was saying beforehand and then you have that opportunity for that add-on code to be used in the other vascular bed now as with the add-on codes for this particular area. You have an opportunity to bill for the 1, the maximum 1 angioplasty atherectomy or stent code, and then you have the 2 vessels for, um, the other add-ons. So now this is brand new, something that we haven't seen before. There's new opportunities as for those add-on codes to be used within this particular territory. And then conversely, excuse me, looking at the tibial per uh peritovascular territory, no changes there. We've seen those add-on codes in the past. They're still the same that we see in, uh, today, so they're broken up into the three vascular areas, so your anterior tibial, your posterior tibial, and your perineal arteries, 3 different areas, 3 different codes. So again you have those add-on abilities as well. And then finally this is new for 2026. We have not seen this before, but it's been introduced as the inframaleolar vascular territory. Two vessel beds within this, um, within this area. So you have your dorsalis pedis and then your plantar, uh, arteries. Please note with these codes the only way that you can build for it is if there are angioplasties done so that means no stenting, no artherectomy being performed in those territories with an actual CPT code assigned to it. so brand new, brand new segment within our PAD world and um I've had some several different conversations with physicians who are excited about this. This is a new opportunity for them to be able to bill accordingly. So now we're going to move right into some reimbursement rates and, and we're not going to spend a lot of time on this. Keep in mind these are national averages and we'll go by place of service, but we just wanted to give you guys a feel for how reimbursement has changed and you will see some real differentiation, particularly in the OBL between, uh, straightforward lesions and complex lesions. Looking at the iliac vascular territory from an OBL perspective you can see the reimbursement rates on the left and then you can see the change versus 2025 rates on the right. And you know there's some pretty big swings there particularly if you look at the 37,260 you know that that PTA and stent of a complex lesion in the iliacs that has increased $5600 versus 2025 rates so that really does it's, it's, it's CMS showing that they understand the com that that these are complex procedures and they require more time. And and tools necessary to to treat this. All right, jumping into ILIAC for hospital and ASC, there's not as much differentiation there. Um, one of the big things is that the that CMS chose for 2026 to really keep the payment levels between straightforward and complex the same in the, uh, OPPS, or the outpatient perspective payment systems, which what is what pays hospitals and ASCs. And so you'll see very similar numbers there, but what you do see is just this kind of general trend upwards of reimbursement rates, uh, in that setting, so nothing too extravagant there but just something to be aware of that reimbursement rates are going up about 3 to 4% in the hospital and ASC setting. And so, um, in this particular uh territory again, common denominator here those complex lesions that have been introduced have also been, um, adding in additional reimbursement. Something that we're seeing here for 2025 versus 2026 is just the. Straightforward lesions were pretty much are very similar to what we've seen from last year, but the introduction of these complex lesions has brought in a lot more reimbursement so again when we define what is supposed to be straightforward versus complex, we'll help dictate exactly what your reimbursement expectations should be. Um, and then also again with this new territory you do have add-on codes so there's a the ability for you to have that additional reimbursement that wasn't there in 25. So this is something that's brand new and we just wanted to make sure everybody was aware of those. And then moving on for the hospital outpatient and AC pretty much similar to what you see for the iliac, a very slight increase. It was just our typical 2025 to 26% increase, roughly about the 3 to 4% that we're. Seeing across the board. So ultimately, again, you have that increased reimbursement. However, with the new add-on codes, because we're talking about the hospital outpatient and ASE, those new codes are not payable because they are packaged into your primary procedure. With you. Right, so for infrapopliteal OBL, you, you know, I wanna point out kind of the same situation we saw with ILIAC and SFA. Is that uh you see some big swings uh between straightforward and complex and so I just wanted to call those out if you look at the comparison versus 2025 column you'll see that for example a complex PTA so this is something you know that you would very commonly do for this patient that is going up $2350 in uh in 2025 uh when you look at um. The stenting for example for complex that's going up almost $2300 and uh atherectomy below the knee is also going up $2500. Then when you look at the combination of all those technologies that's going up $4600. So um some big you know positive changes uh that really reflect the time and the complexity and the tools required to treat this this patient population. Uh, in the hospital ASC, same story, uh, as, as the other setting or the vascular territories 3 to 4%. You're seeing that there there's no real differentiation between straightforward and complex and and we know that CMS is going to do something about that in the future but they've chosen to wait and gather procedure cost data from claims and then they'll make a determination on on what they do with those and and how they start to bifurcate the the payment between those in the hospital and ASE settings. Alright. And then finally with the new area, the inframalleolar, two different codes, straightforward and complex, still the same kind of um. Uh, trend that we're seeing here, OBLs have a good healthy reimbursement rate between, um, the straightforward and complex lesions, you know, and then also looking at your hospital outpatient, those add-on codes still the same story here. They're gonna be packaged in the hospital outpatient and ASC settings, but you still see that there is going to be some sort of reimbursement that's associated with these new codes. And then finally, as far as support from or for you all is we have a comprehensive reimbursement guide that we are in development right now that lists all of our PAD ESKD and Venus CPT codes. In addition to that, we've also developed a, um, lower extremity revascularization guide. If you have not received. That you can either email us or we can or reach out to your sales rep. This guide is really more so for like a quick starter guide to understand all the different territories, how they're, they're being able to be coded, what's going on with the add-ons that are listed within each vascular territory, a really comprehensive guide that we derived from our CPT manual. And then finally last week we held a or we sponsored a training webinar so if you'd like to go ahead download that QR code this will take you directly to the the training link so you can actually see what was going on from the coding standpoint which gives a lot of different scenarios from uh from how you would actually code for these new procedures in a real world setting. Yeah, thank you, Dion. This was a big hit. We had about 140 physicians attend this, uh, training webinar with their, their coders or their builders, and they probably asked about 20 or 30 questions. They were quite detailed that what you would get is a recording. You would get to see that exact presentation and all the questions that were asked, all the answers that were provided. So if you. Run an OBL or if you have your own practice or if you just want to really get a really in depth understanding of this, uh, please, uh, you know, follow this link and and download that training so with that, that's the end of our presentation um if you have any questions feel free to reach out to myself or Dion. My email is Ben.barclay@BD.com and his is Dion.chen@BD.com. And we're happy to answer any questions you guys might have. And from here, I, uh, my pleasure to turn the time over to Doctor JD Miller. Published Created by
Content on this site is intended for United States Healthcare Professionals Only
