CPT code 43659, 43843, 43999 and Group 1 codes

Bariatic Surgical Management of Mobid 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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11x    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 policy 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 policy 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 LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all the 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) Pub. 100-04, Claims Processing Manual, for further guidance.

0360    Operating Room Services - General Classification

CPT/HCPCS Codes


Group 1 Paragraph

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

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

Note: Use CPT code 43659 when BOTH the gastric band and subcutaneous port components were removed AND replaced.

Note: Use CPT code 43843 to identify open-sleeve gastrectomy.

Note: Use CPT code 43999 to identify: 1) laparoscopic vertical-banded gastroplasty; and 2) open adjustable gastric banding.

Non-covered services: 43842, 43843 and 43999.

(Please note 43999 can be used for LSG between 6/27/2012 and 10/1/2012 per CR 8028. However, all other use will be denied as noted above. Use of this code will result in the claim being suspended for review.)

Group 1 Codes
43644    Lap gastric bypass/roux-en-y
43645    Lap gastr bypass incl smll i
43659    Laparoscope proc stom
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
43842    V-band gastroplasty
43843    Gastroplasty w/o v-band
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
43999    Stomach surgery procedure
ICD-9 Codes that Support Medical Necessity


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-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. Coverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria set forth in this LCD requires reporting three appropriate diagnoses. Report the primary diagnosis as 278.01 (morbid obesity). Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2 below. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 43644, 43645, 43770, 43775, 43845, 43846, 43847, and 43848:

Group 1 Codes
250.00    DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.02    DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.10    DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.12    DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.20    DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.22    DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.30    DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.32    DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.40    DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.42    DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.50    DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.52    DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.60    DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.62    DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.70    DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.72    DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.80    DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.82    DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
250.90    DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
250.92    DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
272.0    PURE HYPERCHOLESTEROLEMIA
272.1    PURE HYPERGLYCERIDEMIA
272.2    MIXED HYPERLIPIDEMIA
272.3    HYPERCHYLOMICRONEMIA
272.4    OTHER AND UNSPECIFIED HYPERLIPIDEMIA
278.03    OBESITY HYPOVENTILATION SYNDROME
327.23    OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC)
327.26    SLEEP RELATED HYPOVENTILATION/HYPOXEMIA IN CONDITIONS CLASSIFIABLE ELSEWHERE
348.2    BENIGN INTRACRANIAL HYPERTENSION
401.1    BENIGN ESSENTIAL HYPERTENSION
416.8    OTHER CHRONIC PULMONARY HEART DISEASES
425.8    CARDIOMYOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
530.11*    REFLUX ESOPHAGITIS
571.8    OTHER CHRONIC NONALCOHOLIC LIVER DISEASE
715.15    OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH
715.16    OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG
715.17    OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT
715.25    OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH
715.26    OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG
715.27    OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT
715.35    OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH
715.36    OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG
715.37    OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING ANKLE AND FOOT
715.89    OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED
722.52    DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
722.73    INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION
724.02    SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
724.03    SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

Note: 530.11 This diagnosis is not covered for CPT code 43770.

Group 2 Paragraph : Tertiary Diagnoses


Group 2 Codes
V85.35    BODY MASS INDEX 35.0-35.9, ADULT
V85.36    BODY MASS INDEX 36.0-36.9, ADULT
V85.37    BODY MASS INDEX 37.0-37.9, ADULT
V85.38    BODY MASS INDEX 38.0-38.9, ADULT
V85.39    BODY MASS INDEX 39.0-39.9, ADULT
V85.41    BODY MASS INDEX 40.0-44.9, ADULT
V85.42    BODY MASS INDEX 45.0-49.9, ADULT
V85.43    BODY MASS INDEX 50.0-59.9, ADULT
V85.44    BODY MASS INDEX 60.0-69.9, ADULT
V85.45    BODY MASS INDEX 70 AND OVER, ADULT

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/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 43659, 43771, 43772, 43773, 43774, 43886, 43887, and 43888:

Covered for:

Group 3 Codes
996.59    MECHANICAL COMPLICATION OF OTHER IMPLANT AND INTERNAL DEVICE NOT ELSEWHERE CLASSIFIED
996.60    INFECTION AND INFLAMMATORY REACTION DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT
996.70    OTHER COMPLICATIONS DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

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