43775
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
19.87
Facility
$1000.02
Non-Facility
$1000.02
Documentation Required
- MBSAQIP-accredited hospitals are required to document outcomes for all bariatric procedures.
- Procedure coding may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits; verify coding rules prior to billing.
- Claims must include three ICD-10-CM diagnosis codes: primary code E66.01 (morbid obesity), one secondary BMI code from Z68.35–Z68.39 or Z68.41–Z68.45, and a tertiary code describing the obesity-related comorbid condition.
- For inpatient hospital claims, report ICD-10-PCS procedure code 0DB64Z3 when coverage criteria are satisfied.
Key Coverage Criteria
- Beneficiary must be a Medicare beneficiary to be eligible for coverage of stand-alone LSG.
- Body mass index (BMI) is greater than or equal to 35 kg/m2.
- Patient has at least one obesity-related comorbidity (e.g., type 2 diabetes, hypertension) documented in the medical record.
- Documented prior unsuccessful medical (non-surgical/conservative) treatment for obesity is present.
- Stand-alone laparoscopic sleeve gastrectomy (LSG) is covered for treatment of obesity-related comorbidities when all above conditions are satisfied.
- Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
20 Active Policies
A54923 — Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
J05
A52447 — Laparoscopic Sleeve Gastrectomy (LSG) Medical Policy Article
J06
A57145 — Billing and Coding: Surgical Management of Morbid Obesity
J09
L33411 — Surgical Management of Morbid Obesity
J09
Related Codes
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