43999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Claims must use CPT code 43999 and include the narrative field text 'adjustment of lap-band'.
- When an E/M is billed the same day, append CPT modifier 25 to the E/M code and maintain documentation in the medical record that the E/M was a significantly separate service.
- Medical records must document the reason for adjustment, access to the port, and any services performed during the office visit to support payment.
- Claims must be submitted in accordance with CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 32 Section 150 (Billing Requirements for Bariatric Surgery for Morbid Obesity), including use of the procedure and diagnosis codes listed there and in this local article.
Key Coverage Criteria
- Adjustment of a laparoscopic gastric restrictive device (lap-band) using CPT 43999 is covered when performed in an office setting after the 90-day postoperative global period.
- Bariatric surgery for treatment of co-morbid conditions related to morbid obesity is payable when billed in accordance with CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1 Part 2 Section 100.1.
- Additional diagnoses listed in this local coverage article for Part A procedure codes and the article's listed CPT codes are covered for bariatric surgery to treat co-morbid conditions related to morbid obesity.
- Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
- Services for select minimally invasive GERD procedures are covered when medical necessity is met as defined in the associated Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.
- Transoral Incisionless Fundoplication (TIF, e.g., EsophyX) is covered when performed by a well-trained surgeon for symptomatic chronic gastroesophageal reflux disease (GERD) with symptoms present for >6 months.
18 Active Policies
L34659 — Endoscopic Treatment of GERD
J05
A54923 — Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
J05
A56395 — Billing and Coding: Endoscopic Treatment of GERD
J05
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
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