CPT® Code 35459

Deleted

Quick Reference: CPT 35459

• Former Definition: Transluminal balloon angioplasty, open; tibial-peroneal trunk and branches. Used when the access artery was surgically exposed and directly sutured closed after balloon dilation.
• Status: DELETED — Effective January 1, 2011. This code is no longer active and must not be submitted on any claim for services rendered after December 31, 2010.
• 2011–2025 Replacements: Codes 37228–37235 (tibial/peroneal revascularization, bundled, open or percutaneous). These codes themselves were deleted effective January 1, 2026.
• Current 2026 Replacements: Codes 37254–37299 — 46 new territory-based Lower Extremity Revascularization (LER) codes, organized by vascular territory (iliac, femoral/popliteal, tibial/peroneal, and the new inframalleolar territory). Effective January 1, 2026.
• Key Clinical Context: Tibial-peroneal trunk angioplasty is performed to treat critical limb ischemia (CLI) and peripheral artery disease (PAD), most often in patients with diabetes, end-stage renal disease, or Buerger’s disease.
• Why It Matters: Using deleted CPT 35459 on any claim will result in automatic denial. Understanding the code’s history is essential to correctly audit old records, respond to payer inquiries about pre-2011 procedures, and select the correct current code.

CPT 35459 is one of the most searched “legacy” vascular surgery codes in medical billing — and one of the most misunderstood. The code once described a specific open surgical approach to balloon dilation of the tibial-peroneal trunk and its branches, a critical intervention for saving limbs in patients with severe lower extremity occlusive disease. Understanding its history, the reason for its deletion, and the correct modern replacements is essential for vascular surgery coders, interventional radiologists, interventional cardiologists, and compliance officers.

This complete guide walks through the original CPT 35459 procedure, the 2011 deletion and its replacement codes, the 2025-to-2026 transition that overhauled the entire lower extremity revascularization code family, correct ICD-10 pairings, Medicare reimbursement considerations, modifier guidance, documentation standards, and real-world coding scenarios.

The History of CPT 35459: What It Was and Why It Was Deleted

CPT 35459 previously read: “Transluminal balloon angioplasty, open; tibial-peroneal trunk and branches.” It sat within the 35450–35476 family of open and percutaneous balloon angioplasty codes that, before 2011, separated procedures by both access approach (open vs. percutaneous) and by vessel location.

The Pre-2011 Code Structure

Before January 1, 2011, transluminal angioplasty of lower extremity vessels required two separate codes depending on how the access vessel was handled:

• Open (35459): The access artery was surgically cut down to, a balloon catheter was inserted, the angioplasty was performed, and the artery was repaired with suture after the catheter was removed. This was a more complex procedure requiring open vascular exposure.
• Percutaneous (35470, 35473, 35474): The access vessel was punctured through the skin, sealed by manual pressure or a vascular closure device — no surgical cutdown required.

This distinction created a cumbersome, component-based billing structure that no longer reflected how procedures were actually performed and documented. Additionally, imaging supervision and interpretation codes (75992, 75993) had to be reported separately, adding further complexity.

The 2011 AMA CPT Overhaul: Reason for Deletion

Effective January 1, 2011, the AMA CPT Editorial Panel — in response to a request from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) — deleted CPT 35459 along with 11 other codes (35454, 35456, 35470, 35473, 35474, 35483, 35485, 35493, 35495, 75992, 75993) and replaced them with 16 new bundled lower extremity revascularization codes (37220–37235).

The rationale was clear and compelling: the new codes would better reflect current medical practice by consolidating imaging guidance and the intervention into a single code, no longer distinguishing between open and percutaneous access, and organizing codes by vessel treated (one code per vessel) rather than by access technique or number of devices used.

⚠️ Critical Billing Warning: If CPT 35459 is submitted on any claim for services rendered after December 31, 2010, it will be denied by all payers — including Medicare, Medicaid, and commercial insurers — as an invalid/deleted code. Do not use CPT 35459 for any current or future service. Its only legitimate use today is in reviewing historical records from 2010 or earlier.

The Procedure: Open Tibial-Peroneal Balloon Angioplasty Explained

Although the code is deleted, understanding the original procedure is important for documentation audits, expert witness work, and historical record review.

Anatomy: The Tibial-Peroneal Territory

The tibial-peroneal trunk (also called the tibioperoneal trunk, or TP trunk) is a short arterial segment that arises from the popliteal artery just below the knee and bifurcates into the posterior tibial artery and the peroneal artery. The anterior tibial artery branches off before the trunk, independently supplying the anterior compartment of the leg and continuing as the dorsalis pedis artery in the foot.

When CPT 35459 was active, the code applied specifically to angioplasty involving the TP trunk and its branches — the posterior tibial and peroneal arteries — through a surgical cutdown approach. This territory is critical in limb salvage surgery because these vessels supply the foot.

What “Open” Meant in CPT 35459

The term “open” in CPT 35459 did not refer to open-chest or open-abdomen surgery. Rather, it referred to the access method: an incision was made over the target access vessel (often the common femoral artery), the artery was surgically exposed, the balloon catheter was directly inserted under vision, and after the angioplasty was completed, the arteriotomy was repaired with sutures. This approach was used when percutaneous access was not feasible due to severe calcification, scarring, or when direct visualization of the vessel was required.

Indications That Drove Use of CPT 35459

The clinical scenarios that led to the use of CPT 35459 remain the same conditions for which its 2026 replacement codes are used today:

• Critical Limb Ischemia (CLI): Rest pain, non-healing ulcers, or tissue gangrene secondary to severe tibial-peroneal occlusive disease.
• Peripheral Artery Disease (PAD), TASC C/D lesions: Long-segment occlusions or heavily calcified stenoses of the TP trunk or its branches.
• Diabetic foot ischemia: Diabetic patients frequently have distal disease concentrated in the tibial and peroneal vessels.
• End-stage renal disease (ESRD) with calcific arteriopathy: ESRD accelerates calcification, making tibial vessels a primary target for intervention.
• Buerger’s disease (Thromboangiitis obliterans): Small vessel inflammatory occlusion affecting the tibial and peroneal arteries in young smokers.

2011–2025 Replacement Codes: The 37228–37235 Family

When CPT 35459 was deleted, procedures involving the tibial-peroneal territory were reported using the following new bundled codes (effective 2011 through December 31, 2025):

Key Rules for the 37228–37235 Family (2011–2025)

• One code per vessel, not per lesion: If multiple stenoses in the posterior tibial artery are treated with angioplasty, only one code (37228) is reported — not one per lesion treated.
• Hierarchy matters: When multiple therapies are used in a single vessel (e.g., angioplasty followed by stenting), report only the highest-level therapy code. Stenting (37230) supersedes angioplasty alone (37228).
• TP trunk is not a separate vessel: Work performed on the tibioperoneal trunk is bundled into the code for the posterior tibial or peroneal artery, depending on which distal vessel is also treated. The TP trunk is not coded as a fourth, separate vessel.
• Up to three vessels per leg: The tibial/peroneal territory has three codeable vessels — anterior tibial, posterior tibial, and peroneal — allowing one primary code and up to two add-on codes per unilateral session.
• Bilateral procedures require modifier 50: If both legs are treated in the same session, modifier 50 is applied to the primary code, and add-on codes are reported twice with modifier 59.

⚠️ 2026 Alert: Codes 37228–37235 Are Also Now Deleted. These replacement codes for CPT 35459 — active from 2011 to 2025 — were themselves deleted effective January 1, 2026. If you are coding any tibial/peroneal revascularization for services performed on or after January 1, 2026, you must use the new 37254–37299 code family.

The 2026 Revolution: All 46 New LER Codes (37254–37299)

Effective January 1, 2026, the AMA implemented the most sweeping restructuring of Lower Extremity Revascularization (LER) codes in over a decade. The entire 16-code family (37220–37235) was deleted and replaced with 46 new codes (37254–37299), organized by four distinct vascular territories and further classified by lesion complexity (stenosis vs. occlusion).

The Four Vascular Territories for 2026

New Lesion Complexity Classification for 2026

A critical new dimension added in 2026 is the distinction between:

• Straightforward lesion: A stenosis (partial narrowing of the artery). These generally have a less complex treatment pathway.
• Complex lesion: An occlusion (complete blockage of the artery). These require recanalization, crossing of the total occlusion, and are associated with greater physician work and higher risk.

This distinction is now embedded in the code descriptors for the tibial/peroneal territory codes (37280–37295), providing more accurate valuation for the additional work involved in treating total occlusions.

New Technology in 2026: Intravascular Lithotripsy (IVL)

The 2026 code set also introduced add-on codes for intravascular lithotripsy (IVL) — a newer technology using sonic pressure waves to fracture calcified plaque — for the iliac and femoral/popliteal territories. IVL is not separately coded in the tibial/peroneal or inframalleolar territories.

flowchart TD
    A[Tibial-Peroneal Intervention in 2026] --> B{Which code era?}
    B -->|Pre-2011 historical| C[CPT 35459 - DELETED]
    B -->|2011-2025| D[CPT 37228-37235 - DELETED Jan 2026]
    B -->|2026 onward| E{Which vessel territory?}
    E -->|Iliac| F[37254-37263]
    E -->|Femoral / Popliteal| G[37264-37279]
    E -->|Tibial / Peroneal| H{Lesion type?}
    E -->|Inframalleolar - NEW| I[37296-37299]
    H -->|Stenosis - straightforward| J[Primary: 37280 / Add-on: 37282]
    H -->|Occlusion - complex| K[Primary: 37281 / Add-on: 37283]
    J --> L{Additional intervention same vessel?}
    K --> L
    L -->|Stent| M[+ 37284/37285]
    L -->|Atherectomy| N[+ 37290/37291/37292/37293]
    L -->|Drug-coated balloon| O[+ 37294/37295]

Vascular Territory Rules and Vessel Definitions (2026)

Correct code selection for tibial-peroneal procedures in 2026 depends on understanding how the CPT guidelines define vessels and territories — and these definitions do not always match standard anatomical definitions.

Tibial/Peroneal Territory: 2026 Rules

• The tibial/peroneal territory consists of three separately codeable vessels: the anterior tibial artery, the posterior tibial artery, and the peroneal artery.
• The tibioperoneal (TP) trunk is not a separate, fourth vessel for coding purposes. If lesions in the TP trunk are treated in conjunction with the posterior tibial or peroneal artery, a single code is reported for the combined treatment. The TP trunk is considered part of either the posterior tibial or peroneal territory depending on which distal vessel is also treated.
• However, if the TP trunk is the only vessel treated in the tibial/peroneal territory (i.e., no distal tibial or peroneal vessel is also treated), then it is reported as a single vessel using the appropriate primary code.
• The dorsalis pedis artery is part of the inframalleolar territory (codes 37296–37299), not the tibial territory — a change from pre-2026 convention where it was considered part of the anterior tibial artery.
• The medial plantar artery is also part of the inframalleolar territory.

✅ Practical Example (2026 Coding): A physician performs PTA of the right TP trunk and the right posterior tibial artery at the same session. Under 2026 rules, the TP trunk is not a separate vessel when treated in conjunction with the posterior tibial. Report one primary tibial/peroneal code for angioplasty of a stenosis (straightforward) — NOT two separate codes.

ICD-10 Diagnosis Codes for Tibial-Peroneal Interventions

The following ICD-10-CM codes are the most common diagnoses paired with tibial and peroneal artery interventions (formerly reported under CPT 35459, now reported under codes 37280–37299). These diagnoses must be supported by objective imaging and clinical documentation.

ICD-10 Coding Tip: Specificity Is Critical

For tibial-peroneal interventions, payers and Medicare Administrative Contractors (MACs) scrutinize medical necessity closely. Unspecified codes (e.g., I70.219) raise audit flags. Always document and code to the highest level of specificity available: laterality, vessel involved, and clinical severity (claudication, rest pain, ulceration, or gangrene).

Medicare Coverage, Reimbursement & LCD Policies

Medicare Coverage Overview

Medicare covers percutaneous and open transluminal balloon angioplasty and revascularization of the tibial and peroneal arteries when performed for occlusive disease meeting clinical criteria. Coverage is subject to Local Coverage Determinations (LCDs) issued by Medicare Administrative Contractors (MACs), which vary by region. For lower extremity PTA, the overarching national coverage is provided through NCD 20.7 (Percutaneous Transluminal Angioplasty), which explicitly covers the iliac, femoral, and popliteal arteries. Tibial/peroneal stenting and atherectomy are not covered by a national determination but are implicitly covered, with specific clinical criteria governed by individual MAC LCDs. Providers must verify the applicable LCD for their jurisdiction.

Medical Necessity Requirements

For Medicare to cover tibial-peroneal angioplasty, documentation must generally support at least one of the following:

• Critical limb ischemia (CLI/CLTI): Rest pain, non-healing ulcer, or gangrene.
• Disabling claudication: That has failed at least 3 months of supervised exercise therapy and best medical management (for claudication-only indications; criteria vary by MAC).
• Hemodynamically significant stenosis: Typically defined as ≥50% diameter reduction on angiography with corresponding ABI decline or pressure gradient, in the appropriate clinical context.

CMS Physician Fee Schedule: Conversion Factor & LER Reimbursement

The CY 2026 Medicare Physician Fee Schedule (MPFS) final rule finalized two separate conversion factors:

• Non-APM practitioners: $33.4009 per RVU (a 3.26% increase from 2025).
• Qualifying APM participants: $33.5675 per RVU (a 3.77% increase from 2025).

This increase was driven in part by the 2.5% positive adjustment enacted by Congress in the One Big Beautiful Bill Act, partially offset by a -2.5% efficiency adjustment applied to non-time-based service RVUs. For tibial/peroneal revascularization specifically, CMS finalized the RUC-recommended work RVU values for the new 46-code LER family, and — following advocacy from the Society for Interventional Radiology (SIR) and others — increased reimbursement for drug-coated balloon supplies and drug-eluting tibial stent supplies.

Important 2026 Note — Facility vs. Non-Facility Reimbursement: The 2026 MPFS final rule also reduced indirect practice expense (PE) payments for services provided in a facility setting (hospital, ASC). This disproportionately affects facility-based vascular interventions, including tibial/peroneal angioplasty performed in a hospital cath lab or ASC. Non-facility (office-based lab or OBL) rates are generally higher. Practices should model the impact on their specific patient mix and site of service mix.

Same-Day Rule and Global Period

• Diagnostic angiogram on the same day: A diagnostic arteriogram (e.g., 75710 with 36247) may be reported separately only if a complete, medically necessary diagnostic study was performed and documented, no previous adequate diagnostic study existed, and the decision to intervene was based on the findings of that day’s diagnostic study. If the intervention is performed from the same access as the diagnostic angiogram, the catheterization code is bundled into the intervention, but the radiology S&I code (75710) may be separately reportable with modifier 59.
• Global period: LER codes (37228–37231, and the new 37280-series) carry a 90-day global surgical period. Routine post-operative visits within 90 days are included in the procedure’s global payment. A separately identifiable E/M service for an unrelated problem requires modifier 24.

Audit-Proof Documentation Standards

Because tibial-peroneal revascularization is a high-dollar, high-scrutiny procedure, documentation must be thorough. Under the 2026 CPT guidelines, the operative note must clearly capture the following elements for accurate code selection and to withstand payer audit or RAC review:

Required Documentation Elements for 2026 LER Codes

• Laterality: Right, left, or bilateral. All LER codes are unilateral.
• Vascular territory: Clearly identify which territory is being treated — iliac, femoral/popliteal, tibial/peroneal, or inframalleolar. If multiple territories are treated in the same session, each must be documented.
• Lesion type (NEW for 2026): The operative report must specify whether each treated lesion is a stenosis (straightforward) or an occlusion (complex). This drives code selection between straightforward and complex code variants.
• Specific vessel treated: Name each vessel treated (e.g., “left posterior tibial artery,” “left peroneal artery”). Do not use generic terms like “tibial vessels.”
• Imaging modality used: Document fluoroscopic guidance, intravascular ultrasound (IVUS) if used, and completion angiography.
• Intervention performed: List each therapy applied — angioplasty, stent type and size, atherectomy device, intravascular lithotripsy if applicable.
• Pre- and post-intervention angiography findings: Document percent stenosis before and after, with pressure measurements or ABI if performed.
• Access: Site of arterial access, approach (antegrade vs. retrograde vs. contralateral), and closure method.
• Unsuccessful crossing documentation: Per 2026 guidelines, if a lesion could not be successfully crossed, the procedure is reported as a diagnostic procedure using catheterization and diagnostic angiography codes — not as a revascularization code. Document crossing attempts and failure clearly.

Audit Red Flags to Avoid

• Generic terms like “tibial vessels treated” without naming specific arteries.
• Failure to specify stenosis vs. occlusion (required for 2026 code selection).
• Claiming multiple add-on codes for the same vessel (one code per vessel, regardless of the number of lesions or balloons used).
• Separately reporting angioplasty when stenting was also performed in the same vessel (angioplasty is bundled into the stent code).
• Using a deleted code (35459 or 37228–37235) on claims for 2026+ services.

Modifier Usage for Tibial-Peroneal Procedures

Modifier 50 — Bilateral Procedure

Because all LER codes are unilateral, modifier 50 is required when the same primary procedure (same territory, same type of intervention) is performed on both legs in the same session. Add-on codes for the second leg are reported a second time with modifier 59 or XS to identify distinct services in different limbs.

Modifier 59 — Distinct Procedural Service

Use modifier 59 (or its X{EPSU} modifiers) to distinguish separately reportable services performed at the same session. Most commonly applied:

• To the diagnostic radiology S&I code (75710) when diagnostic angiography is separately reportable from the intervention.
• To separately reportable IVUS (37252/+37253) performed during the intervention.
• To separately reportable mechanical thrombectomy or thrombolysis codes.

Modifier 22 — Increased Procedural Services

Modifier 22 may be appropriate in unusually complex cases — for example, a densely calcified tibial artery requiring multiple devices, prolonged procedure time, and extraordinary effort beyond the typical service described by the code. A written addendum justifying the complexity and additional time should accompany the claim. Modifier 22 is not a routine modifier and should not be applied reflexively.

Modifier 53 — Discontinued Procedure

If a procedure is started but discontinued before completion due to patient safety concerns (e.g., allergic reaction to contrast, hemodynamic instability), modifier 53 is used. Documentation must clearly explain why the procedure was terminated and what work was completed.

Modifier GC — Teaching Physician

Required for teaching physicians involving residents in the care of a Medicare patient. It certifies that the teaching physician was present for the critical or key portion of the procedure.

Modifier RT/LT — Right/Left

Always append RT (right) or LT (left) to LER codes when reporting unilateral procedures, even though the codes are defined as unilateral. This is required by many MACs and commercial payers to ensure accurate claims processing and prevent duplicate billing.

Bundling Rules: What Is and Is Not Separately Reportable

What Is INCLUDED (Bundled) in LER Codes — Cannot Be Separately Billed

• Vessel access (femoral, popliteal, pedal, or brachial puncture)
• Selective catheterization of the target vessel (no separate 36247, 36248 for the treated vessel’s catheterization — only the access artery catheterization when a diagnostic study from a separate access qualifies)
• Wire and catheter manipulation through the target lesion, including subintimal techniques and reentry devices
• All balloon inflations within the treated vessel (predilation, post-dilation)
• Distal embolic protection device usage
• Fluoroscopic guidance and roadmapping imaging
• Completion angiography to assess the result
• Closure of the access site (suture or vascular closure device)
• Moderate (conscious) sedation
• Drug-coated balloon angioplasty (reported with same code as standard PTA; C2623 HCPCS code is used by the facility for cost reporting)

What Is NOT Included — May Be Separately Reportable

• True diagnostic arteriography (75710 for unilateral lower extremity, 75716 bilateral) — separately reportable when meeting criteria described in the CPT guidelines.
• Intravascular ultrasound (IVUS): 37252 (initial vessel) and +37253 (each additional vessel) are separately reportable with LER codes.
• Mechanical thrombectomy or thrombolysis (e.g., 37184, 37185, 37186, 37211–37214) when performed to clear thrombus, separate from the revascularization.
• Embolization if required for a complication during the procedure.
• Open vascular repair of extensive arterial injury (not the routine closure of the access site).
• Contralateral limb procedures when the identical territory is treated on the other leg (use modifier 50 on the primary code, report add-on codes twice with modifier 59/XS).

Code Comparison: Old vs. New LER Hierarchy

Complex Clinical Coding Scenarios

Scenario 1: Bilateral Tibial Angioplasty for Critical Limb Ischemia (2026 Coding)

Patient: A 68-year-old diabetic male with bilateral rest pain and non-healing right heel ulcer. Angiography demonstrates a 90% stenosis (not occlusion) of the right posterior tibial artery and a 75% stenosis (not occlusion) of the right peroneal artery; separately, a 70% stenosis of the left posterior tibial artery.Procedures: Right: PTA of right posterior tibial artery (straightforward stenosis) + PTA of right peroneal artery (additional vessel, straightforward stenosis). Left: PTA of left posterior tibial artery (straightforward stenosis).

2026 Coding:

• Right tibial/peroneal initial vessel angioplasty — straightforward stenosis primary code (e.g., 37280-RT)
• Right tibial/peroneal additional vessel angioplasty — straightforward stenosis add-on code (e.g., +37288-RT)
• Left tibial/peroneal initial vessel angioplasty — straightforward stenosis primary code (e.g., 37280-50 or 37280-LT with modifier 59 on add-on)

Note: The TP trunk treatment alongside PT artery treatment in the same session = one code, not two. ICD-10: I70.231 (right), I70.232 (left), E11.51.

Scenario 2: TP Trunk Occlusion — Historical (Pre-2011) vs. Current Coding

Historical (pre-2011): A 72-year-old with a complete occlusion of the left tibial-peroneal trunk approached through an open surgical cutdown of the common femoral artery. PTA performed, arteriotomy repaired with suture. This would have been coded with CPT 35459 (open; tibial-peroneal trunk and branches) + the appropriate radiological supervision and interpretation code.Modern equivalent (2026): The same procedure today — whether accessed percutaneously or via open surgical exposure — would be coded using the appropriate tibial/peroneal territory revascularization code for an occlusion (complex lesion), with a higher relative value than a stenosis-only case, from the 37280-series.

Coding takeaway: The “open vs. percutaneous” distinction that defined CPT 35459 no longer exists. The 2026 codes treat both access approaches identically.

Scenario 3: Failed Crossing Attempt — What to Report (2026)

Patient: A 77-year-old with gangrene of the right great toe. Angiography reveals a complete occlusion of the right anterior tibial artery beginning just below the tibial-peroneal trunk. Multiple attempts to cross the occlusion with a guidewire are made, including subintimal technique with a reentry device. Crossing is unsuccessful.2026 Coding Per CPT Guidelines: Per the new 2026 guidelines, an unsuccessful crossing attempt does not qualify as an endovascular intervention. Report: 36247-RT (selective catheterization, third-order) + 75710-59-RT (lower extremity arteriography, unilateral, S&I).

Do NOT report a tibial/peroneal revascularization code. The documentation must clearly note that the lesion was not successfully crossed and no revascularization was achieved.

Scenario 4: Tibial Angioplasty + Separately Reportable IVUS (2026)

Patient: 60-year-old with severe calcific posterior tibial stenosis. PTA performed with 4.0 mm balloon. IVUS performed before and after intervention to assess vessel sizing and stent apposition.2026 Coding:

• Primary tibial/peroneal angioplasty code (straightforward stenosis) — from 37280-series
• 37252-RT — Intravascular ultrasound, initial vessel (separately reportable)

Note: IVUS is separately reportable with LER codes in 2026. Unlike many bundled services, IVUS retains independent coding status.