LCD Reference Article Billing and Coding Article

Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity

A54923

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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This article is not in direct support of an LCD.

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Source Article ID
N/A
Article ID
A54923
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
Article Type
Billing and Coding
Original Effective Date
03/01/2016
Revision Effective Date
08/31/2023
Revision Ending Date
N/A
Retirement Date
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CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Article Text

Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.

Bariatric Surgery for Treatment of Morbid Obesity is a payable Medicare service when billed in accordance with instructions outlined in:

CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual,
Chapter 1 – Coverage Determinations, Part 2 (Sections 90-160.2), Section 100.1 - Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (Effective September 24, 2013).

CMS Pub 100-04 Medicare Claims Processing Manual,
Chapter 32 – Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity.

This local coverage Article lists the additional diagnoses that are covered for bariatric surgery for treatment of co-morbid conditions related to morbid obesity for the procedure codes for Part A providers found in CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 32 – Billing requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity; and the listed CPT codes in the article. The diagnoses codes listed in section 150.5.1 - ICD Codes for Type II Diabetes Mellitus Complication are not included in this article but are covered based on the IOM.

Response To Comments

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1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

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Group 1 Codes
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)
43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)
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

(1 Code)
Group 2 Paragraph

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Group 2 Codes
Code Description
43999 UNLISTED PROCEDURE, STOMACH
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

THREE Diagnoses are necessary for CPT Group 1 Codes:

Claims for any bariatric surgical procedure must include the Primary Obesity Diagnosis Code (Group 1 Codes) and one of the Body Mass Index (BMI) Codes (Group 2 Codes) and a Co-Morbidity Diagnoses Code(s) (Group 3 Codes). See CMS PUB 100-04 Medicare Claim Processing Manual, Chapter 32 – Billing Requirement for Special Services, Section 150.4 – ICD Diagnosis Codes for Bariatric Surgery.


Group 1 Codes
Code Description
E66.01 Morbid (severe) obesity due to excess calories

Group 2

(10 Codes)
Group 2 Paragraph

AND Mass Index Diagnosis (BMI) Codes greater than or equal to 35 as described in CMS PUB 100-04 Medicare Claim Processing Manual, Chapter 32 – Billing Requirement for Special Services, Section 150.5 – ICD Diagnosis codes for BMI ≥35.

Group 2 Codes
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] 50.0-59.9, adult
Z68.44 Body mass index [BMI] 60.0-69.9, adult
Z68.45 Body mass index [BMI] 70 or greater, adult

Group 3

(151 Codes)
Group 3 Paragraph

AND Co-Morbidity Diagnosis Code (This list is in addition to the diagnoses codes in CMS PUB 100-04 Medicare Claim Processing Manual, Chapter 32 – Billing Requirement for Special Services, Section 150.5.1 – ICD Codes for Type II Diabetes Mellitus Complication.)

Group 3 Codes
Code Description
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3541 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E10.3542 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E10.3543 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E10.9 Type 1 diabetes mellitus without complications
E24.0 Pituitary-dependent Cushing's disease
E24.2 Drug-induced Cushing's syndrome
E24.3 Ectopic ACTH syndrome
E24.4 Alcohol-induced pseudo-Cushing's syndrome
E24.8 Other Cushing's syndrome
G47.01 Insomnia due to medical condition
G47.14 Hypersomnia due to medical condition
G47.33 Obstructive sleep apnea (adult) (pediatric)
G93.2 Benign intracranial hypertension
I10 Essential (primary) hypertension
I11.0 Hypertensive heart disease with heart failure
I11.9 Hypertensive heart disease without heart failure
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I15.0 Renovascular hypertension
I15.8 Other secondary hypertension
I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.89 Other specified pulmonary heart diseases
M16.0 Bilateral primary osteoarthritis of hip
M16.11 Unilateral primary osteoarthritis, right hip
M16.12 Unilateral primary osteoarthritis, left hip
M16.2 Bilateral osteoarthritis resulting from hip dysplasia
M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip
M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip
M16.4 Bilateral post-traumatic osteoarthritis of hip
M16.51 Unilateral post-traumatic osteoarthritis, right hip
M16.52 Unilateral post-traumatic osteoarthritis, left hip
M16.6 Other bilateral secondary osteoarthritis of hip
M16.7 Other unilateral secondary osteoarthritis of hip
M17.0 Bilateral primary osteoarthritis of knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.31 Unilateral post-traumatic osteoarthritis, right knee
M17.32 Unilateral post-traumatic osteoarthritis, left knee
M17.4 Other bilateral secondary osteoarthritis of knee
M17.5 Other unilateral secondary osteoarthritis of knee
M19.071 Primary osteoarthritis, right ankle and foot
M19.072 Primary osteoarthritis, left ankle and foot
M19.09 Primary osteoarthritis, other specified site
M19.171 Post-traumatic osteoarthritis, right ankle and foot
M19.172 Post-traumatic osteoarthritis, left ankle and foot
M19.19 Post-traumatic osteoarthritis, other specified site
M19.271 Secondary osteoarthritis, right ankle and foot
M19.272 Secondary osteoarthritis, left ankle and foot
M19.29 Secondary osteoarthritis, other specified site
M24.151 Other articular cartilage disorders, right hip
M24.152 Other articular cartilage disorders, left hip
M24.171 Other articular cartilage disorders, right ankle
M24.172 Other articular cartilage disorders, left ankle
M24.174 Other articular cartilage disorders, right foot
M24.175 Other articular cartilage disorders, left foot
M24.19 Other articular cartilage disorders, other specified site
M43.21 Fusion of spine, occipito-atlanto-axial region
M43.22 Fusion of spine, cervical region
M43.23 Fusion of spine, cervicothoracic region
M43.24 Fusion of spine, thoracic region
M43.25 Fusion of spine, thoracolumbar region
M43.26 Fusion of spine, lumbar region
M43.27 Fusion of spine, lumbosacral region
M43.28 Fusion of spine, sacral and sacrococcygeal region
M46.46 Discitis, unspecified, lumbar region
M46.47 Discitis, unspecified, lumbosacral region
M51.06 Intervertebral disc disorders with myelopathy, lumbar region
M51.34 Other intervertebral disc degeneration, thoracic region
M51.35 Other intervertebral disc degeneration, thoracolumbar region
M51.36 Other intervertebral disc degeneration, lumbar region
M51.37 Other intervertebral disc degeneration, lumbosacral region
M51.86 Other intervertebral disc disorders, lumbar region
M51.87 Other intervertebral disc disorders, lumbosacral region
M53.80 Other specified dorsopathies, site unspecified
M53.84 Other specified dorsopathies, thoracic region
M53.85 Other specified dorsopathies, thoracolumbar region

Group 4

(1 Code)
Group 4 Paragraph

ICD-10 Codes that support medical necessity for CPT code 43999 when used to report gastric restrictive adjustment.

Group 4 Codes
Code Description
Z46.51 Encounter for fitting and adjustment of gastric lap band
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

Those not listed.

Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description
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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.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
08/31/2023 R14

Posted 12/28/2023 Under CPT/HCPCS Codes Group 1 Codes removed CPT codes 43771, 43772, 43773, 43774, and 43848 as these were added in error effective 08/31/2023.

08/31/2023 R13

Posted 08/31/2023 Under CPT/HCPCS Codes Group 1 Codes added CPT codes 43771, 43772, 43773, 43774, and 43848. Review completed 07/21/2023.

10/01/2021 R12

09/30/2021 ICD 10 Annual Code Update description change to Group 2 code Z68.41 effective 10/1/2021.

Under Group 3 Codes deleted E10.8, E24.9, G47.30, M43.20, and M53.9 as they are unspecified codes. The deletion of these codes is effective 11/13/2021. Review completed 8/24/2021.

10/01/2020 R11

10/01/2020: ICD-10 CM annual code update: description changes to Group 2 codes Z68.35-Z68.45.Group 3 Codes: added M19.09, M19.19, M19.29, and M24.19.

11/01/2019 R10

Content has been moved to the new template.

10/01/2019 R9

Content has been moved to the new template.

10/01/2019 R8

09/26/2019. ICD-10 CM annual code update: description change to code Z68.43 in Group 2 Codes. Review completed 09/03/2019.

10/01/2018 R7

10/01/2018 ICD-10 code updates: description change to code Z68.43 in Group 2.

03/01/2018 R6

03/01/2018 Annual review done 02/02/2018. Formatting changes made. No change in coverage.

10/01/2017 R5

 10/01/2017 ICD-10 code updates: In Group 3 deleted code I27.2 and added codes I27.20, I27.21, I27.23, I27.24, and I27.29.

 

03/01/2017 R4 03/01/2017 Annual review done 02/02/2017. No change in coverage.
10/01/2016 R3 10/01/2016 Per ICD-10 Code Updates: In Group 3 deleted codes E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, and E10.359; and added codes E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, E10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E10.37X1, E10.37X2, and E10.37X3, effective 10/01/2016.
03/01/2016 R2 04/07/2016 - Corrected typo/HTML coding for "greater than or equal to" symbol in paragraph 2 of ICD-10 codes section and added CMS Manual Explanations URL.
03/01/2016 R1 04/01/2016 the article only lists the additional diagnoses codes covered beyond the codes found in the IOM. The sources of information from the IOM are listed behind each Paragraph under the ICD-10 Codes that are covered.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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