The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive.
CPT® Code Description
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43659 Unlisted laparoscopy procedure, stomach 43770
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port
components)
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
Bariatric Surgery.doc Page 32 of 42 gastric restrictive device and subcutaneous port components
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)
43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43845
Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43860
Revision of gastrojejunal anastomosis (gastrojejunostomy) with
reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy
43865
Revision of gastrojejunal anastomosis (gastrojejunostomy) with
reconstruction, with or without partial gastrectomy or intestine resection with vagotomy
43886 Gastric restrictive procedure, open; revision of subcutaneous port component only
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
CPT® is a registered trademark of the American Medical Association. CPT® Code
(Not medically necessary)
Description
43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum
43648 Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum
43881 Implantation or replacement of gastric neurostimulator electrodes, antrum, open
43882 Revision or removal of gastric neurostimulator electrodes, antrum, open 43999 Unlisted procedure stomach
64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
95980 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status,
Bariatric Surgery.doc Page 33 of 42 electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming
95981
Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming
95982
Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming
0312T
Vagus nerve blocking therapy 9morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ) with implantation of pulse generator, includes programming
0313T Laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
0314T Laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator
0315T
Removal of pulse generator 0316T
Replacement of pulse generator
0317T Neurostimulator pulse generator electronic analysis, included reprogramming when performed
CPT® is a registered trademark of the American Medical Association
Coding Clarification
Laparoscopic sleeve gastrectomy should not be reported with CPT code 43659. Utilize CPT code 43775 to report laparoscopic sleeve gastrectomy.
ICD-9 Code Description
278.00 Obesity, unspecified 278.01 Morbid obesity
539.01 Infection due to gastric band procedure
539.09 Other complications of gastric band procedure 539.81 Infection due to other bariatric procedure
539.89 Other complications of other bariatric procedure V85.35 Body Mass Index 35.0-35.9, adult
V85.36 Body Mass Index 36.0-36.9, adult V85.37 Body Mass Index 37.0-37.9, adult V85.38 Body Mass Index 38.0-38.9, adult V85.39 Body Mass Index 39.0-39.9, adult V85.41 Body Mass Index 40.0-44.9, adult
Bariatric Surgery.doc Page 34 of 42 V85.42 Body Mass Index 45.0-49.9, adult
V85.43 Body Mass Index 50.0-59.9, adult V85.44 Body Mass Index 60.0-69.9, adult V85.45 Body Mass Index 70 and over, adult ICD-10 Codes (Preview Draft)
In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2015, a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change.
ICD-10 Diagnosis Code (effective
10/01/15)
Description
E66.01 Morbid (severe) obesity due to excess calories E66.09 Other obesity due to excess calories
E66.1 Drug-induced obesity E66.8 Other obesity
E66.9 Obesity, unspecified
K95.01 Infection due to gastric band procedure
K95.09 Other complications of gastric band procedure K95.81 Infection due to other bariatric procedure
K95.89 Other complications of other bariatric procedure Z68.35 Body mass index (BMI) 35.0-35.9, adult
Z68.36 Body mass index (BMI) 36.0-36.9, adult Z68.37 Body mass index (BMI) 37.0-37.9, adult Z68.38 Body mass index (BMI) 38.0-38.9, adult Z68.39 Body mass index (BMI) 39.0-39.9, adult Z68.41 Body mass index (BMI) 40.0-44.9, adult Z68.42 Body mass index (BMI) 45.0-49.9, adult Z68.43 Body mass index (BMI) 50.0-59.9, adult Z68.44 Body mass index (BMI) 60.0-69.9, adult Z68.45 Body mass index (BMI) 70 or greater, adult