T85.518A — Breakdown (mechanical) of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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.
Key Coverage Criteria
- 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.
2 Active Policies
A56422 — Billing and Coding: Bariatric Surgical Management of Morbid Obesity
J12
L35022 — Bariatric Surgical Management of Morbid Obesity
J12
Related Codes
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