E66.811 — Obesity, class 1
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
- Hospital inpatient claims must report the principal diagnosis in UB-04 Form Locator 67 and up to eight additional ICD-10-CM codes in FL 67A-67Q; admitting diagnosis is required in FL 69.
- Hospital outpatient claims must report the full ICD-10-CM code for the diagnosis chiefly responsible for the outpatient services in FL 67, or the presenting symptom or Z00.00–Z13.9 if no definitive diagnosis.
- The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit or operative report to support medical necessity.
Key Coverage Criteria
- Outpatient psychiatry and psychology services are payable under Medicare Part B when provided in accepted places of service listed (e.g., office 11, outpatient hospital 22, telehealth in patient's home 10, etc.).
- Services of physicians, clinical psychologists, physician assistants, nurse practitioners, and clinical nurse specialists should be billed to the Part B Medicare Administrative Contractor (MAC).
- Individual psychotherapy CPT codes must be used when the primary focus of the treatment encounter is psychotherapy.
- When the visit is primarily psychotherapy and also includes pharmacological management, bill the appropriate psychotherapy code (which includes E/M) and CPT 90863 for pharmacological management in addition.
- For services that require a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- For diagnostic tests, report the test result if known; if not known, report the symptom that prompted the test.
15 Active Policies
L40271 — MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
J05
A60305 — Billing and Coding: MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
J05
L37535 — Vitamin D Assay Testing
J06
A57736 — Billing and Coding: Vitamin D Assay Testing
J06
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