LCD Reference Article Billing and Coding Article

Billing and Coding: Bariatric Surgical Management of Morbid Obesity

A56422

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Draft Article
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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56422
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Bariatric Surgical Management of Morbid Obesity
Article Type
Billing and Coding
Original Effective Date
03/28/2019
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35022 (Bariatric Surgical Management). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

CPT code 43659 should be used when BOTH the gastric band and subcutaneous port components were removed AND replaced.

CPT code 43843 should be used to bill the following test and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:

  • Open-sleeve gastrectomy

Not otherwise classified (NOC) CPT code 43999 should be used to bill the following tests and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:

  • Laparoscopic vertical-banded gastroplasty
  • Open adjustable gastric banding

Coverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria set forth in the LCD requires reporting three appropriate diagnoses. Report the primary diagnosis as E66.01 (morbid obesity). Report a secondary diagnosis from ICD-10 Code group 1 and a tertiary diagnosis from ICD-10 Code group 2.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
N/A

Revenue Codes

Code Description
0360 Operating Room Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(16 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Non-covered services: 43842, 43843 and 43999

Group 1 Codes
Code Description
43644 Lap gastric bypass/roux-en-y
43645 Lap gastr bypass incl smll i
43659 Unlisted laps px stomach
43770 Lap place gastr adj device
43771 Lap revise gastr adj device
43772 Lap rmvl gastr adj device
43773 Lap replace gastr adj device
43774 Lap rmvl gastr adj all parts
43775 Lap sleeve gastrectomy
43845 Gastroplasty duodenal switch
43846 Gastric bypass for obesity
43847 Gastric bypass incl small i
43848 Revision gastroplasty
43886 Revise gastric port open
43887 Remove gastric port open
43888 Change gastric port open
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(239 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes 43644, 43645, 43770, 43775, 43845, 43846, 43847 and 43848:

Group 1 Codes
Code Description
A18.84 Tuberculosis of heart
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E11.3532 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E11.3541 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E11.3542 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E11.3543 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.9 Type 2 diabetes mellitus without complications
E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E13.01 Other specified diabetes mellitus with hyperosmolarity with coma
E13.10 Other specified diabetes mellitus with ketoacidosis without coma
E13.11 Other specified diabetes mellitus with ketoacidosis with coma
E13.21 Other specified diabetes mellitus with diabetic nephropathy
E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease
E13.29 Other specified diabetes mellitus with other diabetic kidney complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E13.3541 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E13.3542 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E13.3543 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E13.37X9 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59 Other specified diabetes mellitus with other circulatory complications
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
E13.8 Other specified diabetes mellitus with unspecified complications
E13.9 Other specified diabetes mellitus without complications
E66.2 Morbid (severe) obesity with alveolar hypoventilation
E78.00 Pure hypercholesterolemia, unspecified
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.3 Hyperchylomicronemia
E78.49 Other hyperlipidemia
E78.5 Hyperlipidemia, unspecified
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.36 Sleep related hypoventilation in conditions classified elsewhere
G93.2 Benign intracranial hypertension
I10 Essential (primary) hypertension
I1A.0 Resistant hypertension
I27.29 Other secondary pulmonary hypertension
I27.89 Other specified pulmonary heart diseases
I43 Cardiomyopathy in diseases classified elsewhere
K21.00* Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01* Gastro-esophageal reflux disease with esophagitis, with bleeding
K75.81 Nonalcoholic steatohepatitis (NASH)
K76.0 Fatty (change of) liver, not elsewhere classified
K76.89 Other specified diseases of liver
M15.3 Secondary multiple arthritis
M15.8 Other polyosteoarthritis
M16.0 Bilateral primary osteoarthritis of hip
M16.10 Unilateral primary osteoarthritis, unspecified hip
M16.11 Unilateral primary osteoarthritis, right hip
M16.12 Unilateral primary osteoarthritis, left hip
M16.2 Bilateral osteoarthritis resulting from hip dysplasia
M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip
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
M16.50 Unilateral post-traumatic osteoarthritis, unspecified 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
M16.9 Osteoarthritis of hip, unspecified
M17.0 Bilateral primary osteoarthritis of knee
M17.10 Unilateral primary osteoarthritis, unspecified knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.30 Unilateral post-traumatic osteoarthritis, unspecified 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
M17.9 Osteoarthritis of knee, unspecified
M19.071 Primary osteoarthritis, right ankle and foot
M19.072 Primary osteoarthritis, left ankle and foot
M19.079 Primary osteoarthritis, unspecified ankle and foot
M19.171 Post-traumatic osteoarthritis, right ankle and foot
M19.172 Post-traumatic osteoarthritis, left ankle and foot
M19.179 Post-traumatic osteoarthritis, unspecified ankle and foot
M19.271 Secondary osteoarthritis, right ankle and foot
M19.272 Secondary osteoarthritis, left ankle and foot
M19.279 Secondary osteoarthritis, unspecified ankle and foot
M19.90 Unspecified osteoarthritis, unspecified site
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M48.07 Spinal stenosis, lumbosacral region
M51.06 Intervertebral disc disorders with myelopathy, lumbar region
M51.36 Other intervertebral disc degeneration, lumbar region
M51.37 Other intervertebral disc degeneration, lumbosacral region
M99.23 Subluxation stenosis of neural canal of lumbar region
M99.33 Osseous stenosis of neural canal of lumbar region
M99.43 Connective tissue stenosis of neural canal of lumbar region
M99.53 Intervertebral disc stenosis of neural canal of lumbar region
M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10 codes K21.00 and K21.01 are not covered for CPT code 43770.

Group 2

(10 Codes)
Group 2 Paragraph

Tertiary Diagnoses

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

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

(13 Codes)
Group 3 Paragraph

Coverage for replacing a defective device or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss requires reporting of one diagnosis. The following list includes only those diagnoses for which the identified CPT procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes 43659, 43771, 43772, 43773, 43774, 43886, 43887 and 43888:

Group 3 Codes
Code Description
K95.01 Infection due to gastric band procedure
K95.09 Other complications of gastric band procedure
K95.81 Infection due to other bariatric procedure
K95.89 Other complications of other bariatric procedure
T85.518A Breakdown (mechanical) of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
T85.528A Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
T85.598A Other mechanical complication of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
T85.612A Breakdown (mechanical) of permanent sutures, initial encounter
T85.622A Displacement of permanent sutures, initial encounter
T85.638A Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter
T85.692A Other mechanical complication of permanent sutures, initial encounter
T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter
T85.9XXA Unspecified complication of internal prosthetic device, implant and graft, initial encounter
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
011x Hospital Inpatient (Including Medicare Part A)
N/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.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description
0360 Operating Room Services - General Classification
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R6

Article revised and published on 10/26/2023 effective for dates of service on and after 10/01/2023 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has been added to Group 1 Codes: I1A.0.

01/01/2023 R5

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 43659 in 'Group 1 Codes'.

10/01/2021 R4

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has undergone a descriptor change: Z68.41 in Group 2 Codes.

10/01/2020 R3

Article revised and published on 10/01/2020 effective for dates of service on and after 10/01/2020 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10 codes have been added to the article: K21.00 and K21.01 in Group 1 Codes and in Group 1 Medical Necessity ICD-10 Asterisk Explanation. The following ICD-10 code has been deleted and therefore has been removed from the article: K21.0 in Group 1 Codes and in Group 1 Medical Necessity ICD-10 Asterisk Explanation. The following ICD-10 codes have undergone a descriptor change: Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, and Z68.45 for Group 2 Codes. Minor formatting changes made through the coding section.

10/01/2019 R2

Article revised and published on 10/17/2019 effective for dates of service on and after 10/01/2019 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has undergone a descriptor change: Z68.43. An asterisk has been added to ICD-10 code K21.0 in the Group 1 ICD-10 Code table and the note related to this code has been moved from the ICD-1- Code Group 1 paragraph to the asterisk explanation at the bottom of the code table. Please note, system changes have been made to our articles in response to CMS Change Request 10901. The Coding Section has been reordered and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

04/04/2019 R1

Article revised and published on 5/30/19 effective for dates of service on and after 4/4/19, in response to an inquiry, to add K95.01, K95.09, K95.81 and K95.89 to group 3. The related LCD was reviewed and it was determined that the LCD supports these diagnoses. These codes are more specific and appropriate to be used, therefore they have been added.

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