The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination 100.1.

As of the effective date of this article revision Medicare (CMS) has established by NCD 100.1 that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity.
1. Roux-en-Y Gastric Bypass (RYGBP)
2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS)
3. Laparoscopic Adjustable Gastric Banding (AGB)
4. Laparoscopic Sleeve Gastrectomy

To be eligible for bariatric surgery the patient must have a body-mass index (BMI) ≥ 35, and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant.

Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD:

1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patient’s weight and BMI, current dietary regimen and physical activity (e.g. exercise program).
2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.
3. A thorough multidisciplinary evaluation is required within the previous six months which includes ALL of the following:
a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s)
b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiary’s primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgery
c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements
d. a nutritional evaluation by a physician or registered dietician.

Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZ

Nationally Covered Inpatient Facility ICD-10-CM Procedure Codes

For services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery:

Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes:

0DB64Z3
0DV64CZ
0D16479
0D1647A
0D1647B
0D1647L
0D164J9
0D164JA
0D164JB
0D164JL
0D164K9
0D164KA
0D164KB
0D164KL
0D164Z9
0D164ZA
0D164ZB
0D164ZL

Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes:

0D16079
0D1607A
0D1607B
0D1607L
0D160J9
0D160JA
0D160JB
0D160JL
0D160K9
0D160KA
0D160KB
0D160KL
0D160Z9
0D160ZA
0D160ZB
0D160ZL
0D16879
0D1687A
0D1687B
0D1687L
0D168J9
0D168JA
0D168JB
0D168JL
0D168K9
0D168KA
0D168KB
0D168KL
0D168Z9
0D168ZA
0D168ZB
0D168ZL

To describe either laparoscopic or open BPD with DS or GRDS, one code from each of the following three groups must be on the claim:

Group 1:
0DB60Z3
0DB60ZZ
0DB63Z3
0DB63ZZ
0DB67Z3
0DB67ZZ
0DB68Z3

Group 2:
One code from Groups A-C below is required.

Group A:
0DB80ZZ
0DB90ZZ
0DBB0ZZ

Group B:
0D160ZB

Group C:
0F190Z3

Group 3:
0D19079
0D1907A
0D1907B
0D190J9
0D190JA
0D190JB
0D190K9
0D190KA
0D190KB
0D190Z9
0D190ZA
0D190ZB
0D19479
0D1947A
0D1947B
0D194J9
0D194JA
0D194JB
0D194K9
0D194KA
0D194KB
0D194Z9
0D194ZA
0D194ZB
0D19879
0D1987A
0D1987B
0D198J9
0D198JA
0D198JB
0D198K9
0D198KA
0D198KB
0D198Z9
0D198ZA
0D198ZB
0D1A07A
0D1A07B
0D1A0JA
0D1A0JB
0D1A0KA
0D1A0KB
0D1A0ZA
0D1A0ZB
0D1A47A
0D1A47B
0D1A4JA
0D1A4JB
0D1A4KA
0D1A4KB
0D1A4ZA
0D1A4ZB
0D1A87A
0D1A87B
0D1A8JA
0D1A8JB
0D1A8KA
0D1A8KB
0D1A8ZA
0D1A8ZB
0D1A8ZH
0D1B07B
0D1B0JB
0D1B0KB
0D1B0ZB
0D1B47B
0D1B4JB
0D1B4KB
0D1B4ZB
0D1B87B
0D1B8JB
0D1B8KB
0D1B8ZB
0D1B8ZH

NOTE: There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered.

Nationally Non-Covered Procedures

For services on or after February 21, 2006, Medicare (CMS) has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01):
• Open adjustable gastric banding (Billed with a Not Otherwise Classified (NOC) code)
• Open sleeve gastrectomy;
• Laparoscopic sleeve gastrectomy (prior to June 27, 2012);
• Open and laparoscopic vertical banded gastroplasty;
• Intestinal bypass surgery; and,
• Gastric balloon for treatment of obesity.


Coding Information

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Bill Type Codes Information Table

CODE DESCRIPTION
011x Hospital Inpatient (Including Medicare Part A)
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph:
Nationally Covered CPT Procedure Codes

For services on or after February 21, 2006, the following CPT procedure codes are covered for bariatric surgery:



Group 1 Codes:

CPT/HCPCS Codes Information Table

CODE DESCRIPTION

43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)

43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS)

43845 GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

43846 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY

43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

Group 2 Paragraph:
Noridian Local Coverage for Laparoscopic Sleeve Gastrectomy



Group 2 Codes:

CPT/HCPCS Codes Information Table

CODE DESCRIPTION

43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)

ICD-10 Codes that are Covered

Group 1 Paragraph:

To ensure proper claims processing, claims must contain the following information:
• CPT 43775 or ICD-10-PCS 0DV64CZ
• The ICD-10-CM code E66.01 (Morbid (severe) obesity due to excess calories),
• An ICD-10-CM code reflecting the co-morbid condition necessitating the procedure (e.g., diabetes, hypertension, cardiac or respiratory diseases) and
• An ICD-10-CM code describing the patient’s BMI.

Acceptable ICD-10-CM codes describing the co-morbid condition and supporting medical necessity for bariatric surgical procedures are:

ICD-10 CODE DESCRIPTION

E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3531 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E08.3532 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E08.3533 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3541 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E08.3542 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E08.3543 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye
E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye
E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye
E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye
E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.59 Diabetes mellitus due to underlying condition with other circulatory complications
E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy
E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E08.628 Diabetes mellitus due to underlying condition with other skin complications
E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications
E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E08.9 Diabetes mellitus due to underlying condition without complications
E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma
E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma
E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease
E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

ICD-10 CODE DESCRIPTION
Z68.35 Body mass index (BMI) 35.0-35.9, adult
Z68.36 Body mass index (BMI) 36.0-36.9, adult
Z68.37 Body mass index (BMI) 37.0-37.9, adult
Z68.38 Body mass index (BMI) 38.0-38.9, adult
Z68.39 Body mass index (BMI) 39.0-39.9, adult
Z68.41 Body mass index (BMI) 40.0-44.9, adult
Z68.42 Body mass index (BMI) 45.0-49.9, adult
Z68.43 Body mass index (BMI) 50-59.9, adult
Z68.44 Body mass index (BMI) 60.0-69.9, adult
Z68.45 Body mass index (BMI) 70 or greater, adult