Does 43774 require prior authorization?

No, 43774 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 43774?

Medicare facility rate: $907.50. Non-facility rate: $907.50. Work RVU: 15.37.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

15.37

Facility

$907.50

Non-Facility

$907.50

Claims for covered bariatric surgery must include three diagnosis codes with the primary diagnosis as E66.01, E66.812, or E66.813 and secondary/tertiary diagnoses from the specified ICD-10-CM code groups (group 1 and group 2).
When using CPT 43843 or CPT 43999 to bill a Not Otherwise Classified (NOC) or specific open procedures, include a note identifying the specific test/procedure performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Refer to LCD L35022 for complete reasonable-and-necessary documentation requirements and retain supporting medical records as required by Medicare policy.
Medical record must document BMI consistent with national policy eligibility requirements at time of surgery.

Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
Clinically significant obstructive sleep apnea is an accepted comorbid indication.
Obesity-related hypoventilation is an accepted comorbid indication.
Refractory hyperlipidemia not controllable with diet and maximal lipid-lowering medication is an accepted comorbid indication.

A56422 — Billing and Coding: Bariatric Surgical Management of Morbid Obesity

J12

L35022 — Bariatric Surgical Management of Morbid Obesity

J12

UMR-POL-UMR-bariatric-surgery — Bariatric Surgery

SUREST-POL-SUREST-bariatric-surgery — Bariatric Surgery

CIGNA-0051 — Bariatric Surgery and Procedures - (0051)

Ask Verity about documentation requirements, denial risks, or coverage in your state.