The new Current Procedural Terminology (CPT) codes and associated values for lower extremity revascularization (LER) took effect Jan. 1, 2026. These 46 new codes represent a significant update from the last time these codes were revised in 2011. As noted in the Vascular Specialist article from the January/February 2026 issue, the new code set provides discrete coding for the complexity of the lesion, greater granularity within the femoral-popliteal territory and the addition of codes for the inframalleolar territory as well as intravascular lithotripsy (IVL).
The work values for these codes were proposed by a multidisciplinary team led by the Society for Vascular Surgery (SVS) advisors to the American Medical Association Relative Value Update Committee (RUC). These values were accepted by the Centers for Medicare and Medicaid Services (CMS) and published as part of the CMS Final Rule for 2026. These work values were in large part determined as a result of surveys taken by practicing specialists (primarily cardiologists, radiologists, and vascular surgeons) who practice in sites of service including hospitals, ambulatory care facilities and outpatient provider-owned labs.
The new code revision updates the LER codes to reflect contemporary practice. Recognizing the heterogeneity of the population undergoing intervention allows separation of each code into straightforward and complex. Our belief was that for each code, the work value should go up for complex interventions and down for straightforward interventions. The final result was that of the 16 legacy codes that were separated into 32 straightforward and complex codes, 27 did exactly that. Of the remaining five, two had no change, two went down and one went up.
However, reimbursement is not based solely on the work values alone, but rather the sum of the work, practice expense and professional liability values associated with each CPT code. For those providers who are directly responsible for the practice expense costs, it is no secret that these costs easily eclipse the costs for the physician work associated with each intervention. CMS uses the terms facility and nonfacility to account for the different practice expense values associated with payment in these different environments. For those that are interested in seeing the facility and nonfacility payments for the entire Physician Fee Schedule (PFS) they can be downloaded at the link below.
Practice expense values have two components: indirect and direct. Direct practice expense accounts for clinical labor, supplies and equipment. Indirect practice expense accounts for everything else such as overhead and nonclinical labor (administrative staff, etc.). Indirect practice expense is attributed to each code in a formulaic manner which is beyond the scope of this discussion.
Contemporary practice for LER has clearly evolved from 2011. The 2026 update allowed us to account for new supplies and equipment that represent evolving technology and typical use. As a result, while some codes had efficiencies introduced as a result of separating interventions into straightforward and complex, others saw appropriate increases as a result of the typical use of new technology.
For example, the straightforward femoral-popliteal stent code saw a decrease of roughly 30% compared to the legacy code, while the complex code saw an increase of just over 50% compared to the legacy code. This was a result of a more contemporary assessment of the practice expenses needed to perform these procedures. For anyone interested in seeing the entire list of direct practice expense inputs in the PFS they can be found by downloading “CY 2026 PFS Final Rule Direct PE Inputs” from the link below.
Finally, the addition of IVL as a Category 1 CPT code allows reimbursement in the nonfacility setting for the practice expense costs associated with its use. Worth noting is that there are only codes for IVL in the iliac and femoral-popliteal territories given that at the time of submission, there was insufficient data to recommend CPT codes for tibial IVL. The SVS Coding Committee is currently reviewing more recently available data to support submission and valuation of tibial IVL.
In summary, 2026 brought in a significant overhaul of the LER codes and their valuations. While a significant amount of effort was brought to bear regarding appropriate work valuation, the direct practice expense inputs represent a significant component of reimbursement in the nonfacility setting. My thanks to our SVS Coding Committee and in particular the RUC and CPT teams who remain committed to ensuring fair and appropriate recognition of the work we all do every day in every care setting. Please continue to fill out the surveys as they arise so that we can properly represent all of you.
Facility and nonfacility payments for PFS: https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26a
Direct practice expense inputs: https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1832-f
Please note that this is not a comprehensive explanation of the CMS PFS and is only meant for illustrative purposes as it relates to practice expense inputs.
