Z46.51 — Encounter for fitting and adjustment of gastric lap band
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.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
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.
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
- Upper gastrointestinal endoscopy (EGD) is covered for persistent upper abdominal distress that continues despite an appropriate trial of therapy.
- EGD is covered for upper abdominal distress associated with signs suggesting serious organic disease, e.g., prolonged anorexia or weight loss.
- EGD is covered for dysphagia (difficulty swallowing) or odynophagia (painful swallowing).
4 Active Policies
A54923 — Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity
J05
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
ANTHEM-CG-SURG-83 — CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Related Codes
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