E66.813 — Obesity, class 3
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
- Coverage for Type II diabetes mellitus complication diagnosis codes is based on the Internet Only Manual (IOM); include documentation and citations required by IOM when billing these diagnoses.
- Bariatric surgery claims must reference the applicable national coverage determination (CMS Pub 100-03 Chapter 1 Part 2 Section 100.1) when submitting for payment.
- Claims must be supported by documentation required by LCD L34576 (medical records demonstrating eligibility, medical necessity, and any prior authorization if applicable).
Key Coverage Criteria
- 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.
- Billing and coding guidance applies to laparoscopic sleeve gastrectomy (sleeve gastrectomy) performed for severe obesity and is intended to complement LCD L34576.
- Use this policy's billing/coding rules when submitting claims for laparoscopic sleeve gastrectomy; follow the clinical indication criteria in LCD L34576 for medical necessity determinations.
- 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).
20 Active Policies
L40271 — MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
J05
A54923 — Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
J05
A60305 — Billing and Coding: MolDX: Biomarker Testing for Risk Stratification in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis
J05
A57736 — Billing and Coding: Vitamin D Assay Testing
J06
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