By Elina Sabilova, Billing Department, WCH
Q: What is intravascular lithotripsy and how does it work?
Intravascular lithotripsy (IVL) delivers localized pulsatile shock waves through a semi-compliant balloon catheter to fracture both intimal and medial calcium within the arterial wall. Unlike rotational or orbital atherectomy, IVL does not remove tissue — it modifies calcium structure, restoring vessel compliance and enabling effective balloon angioplasty or stent expansion. The balloon is first inflated to a low pressure (4 atm) to establish contact, shock waves are delivered in cycles of 10 pulses, and completion angioplasty follows at 6–8 atm. Soft tissue transmits rather than absorbs the energy, minimizing the risk of perforation or thermal injury.
Q: Which patients are the right candidates?
IVL is indicated in symptomatic PAD (Rutherford 2–6) with moderate-to-severe arterial calcification confirmed on CTA, IVUS, or fluoroscopy. The strongest indications are calcium arc greater than 180° on cross-section, lesion length over 5 cm, or prior balloon failure on the table. It is particularly valuable in diabetic and CKD patients, where medial (Mönckeberg) calcification creates the classic “lead pipe” artery that resists conventional angioplasty. Relative contraindications include severe vessel tortuosity limiting catheter delivery and — with precautions — patients with implanted cardiac devices.
Q: What does the procedure look like in the OBL?
Access is typically retrograde common femoral with ultrasound guidance, using a 6–7 French sheath. After diagnostic angiography, the lesion is crossed with a hydrophilic wire and the IVL catheter is advanced and sized 1:1 to the reference vessel. Pre-dilation with a low-profile balloon is sometimes needed for tight stenoses (>90%) before IVL catheter passage. Each catheter delivers up to 80 pulses; multiple catheters may be used for long lesions. Completion angiography — and IVUS when available — guides the decision to stent. Vascular closure device or manual compression achieves hemostasis. Fluoroscopic guidance and radiological supervision/interpretation are included within the procedure and, as of 2026, are bundled into the new IVL-specific CPT codes.
Q: What changed with CPT coding on January 1, 2026?
Two new add-on codes are now in effect:
CPT 37262 covers IVL in the iliac territory. It must be reported alongside a primary iliac revascularization procedure (code first: 37254–37261) and includes imaging guidance.
CPT 37279 covers IVL in the femoral and popliteal territories. It pairs with a primary femoral/popliteal procedure (code first: 37263–37278) and likewise bundles imaging.
Both codes can be reported twice when procedures are performed bilaterally in a single session.
| CPT | Territory | National Medicare | NY Medicare |
| 37262 | Iliac | $3,409.23 | $4,054.44 |
| 37279 | Femoral/Popliteal | $4,636.04 | $5,513.63 |
Q: What are the most common coding mistakes to avoid?
The single biggest error is billing 37262 or 37279 as standalone codes — both are add-on codes and are invalid without the appropriate primary procedure. A second common mistake is failing to capture bilateral IVL: if both limbs are treated, the add-on code should be reported twice. Third, tibial IVL has no dedicated CPT code in 2026 and must be submitted as an unlisted procedure (CPT 37799) with detailed operative documentation and a letter of medical necessity — providers who skip this step leave significant revenue uncollected.
Q: Is IVL financially viable in the OBL under the new codes?
For most well-selected cases, yes. CPT 37279 (femoral/popliteal) and CPT 37262 (iliac) generate direct add-on reimbursement on top of the primary revascularization procedure. Since CPT 37279 may be billed up to twice per session — once for each vessel treated (Common Femoral/Profunda and SFA/Popliteal) — bilateral or multi-vessel cases significantly increase revenue potential. Exact payment rates vary by geographic locality and are published annually in CMS MPFS Addendum B (conversion factor $33.4009 for CY2026); providers should verify current rates with their local Medicare Administrative Contractor (MAC).
The primary device cost per IVL catheter must be evaluated against composite reimbursement from both the primary procedure code and the applicable add-on code. The key financial levers are accurate bilateral capture, tight code pairing, and commercial payer monitoring — Medicare adoption of the new codes does not guarantee immediate commercial insurer coverage.
Q: What is still missing from the evidence and coding landscape?
Tibial IVL remains the most significant gap on both fronts. Clinically, this is where the highest-acuity CLTI patients present with the most severe calcification, yet there is neither a dedicated CPT code nor robust prospective trial data. The Disrupt PAD III trial established strong 12-month patency outcomes for femoral/popliteal IVL (~75–80% primary patency), but equivalent tibial data are still pending. CPT expansion into tibial territories will be critical to unlocking IVL’s full potential in complex below-the-knee disease.
Selected References
- Tepe G, et al. Disrupt PAD III trial results. JACC Cardiovasc Interv. 2021;14(12):1352–1361.
- Brodmann M, et al. Safety and performance of IVL for calcified peripheral stenoses. J Am Coll Cardiol. 2017;70(8):908–916.
- American Medical Association. CPT 2026 Professional Edition. AMA Press; 2025.
- CMS Physician Fee Schedule Final Rule 2026. CMS.gov. Published November 2025.
- Gerhard-Herman MD, et al. 2016 AHA/ACC PAD guidelines. J Am Coll Cardiol. 2017;69(11):e71–e126.
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