Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement
Covered when medically necessary: CPT®*
Codes
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
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie,
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
Experimental/Investigational/Unproven/Not Covered when used to report any procedure listed as not covered in this coverage policy:
CPT* Codes Description
43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum
43659 Unlisted laparoscopy procedure, stomach
43881 Implantation or replacement 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
0312T Vagus nerve blocking therapy (morbid 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 Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or
replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator 0317T Vagus nerve blocking therapy (morbid obesity); neurostmiulator pulse generator
electronic analysis, includes reprogramming when performed Silicone Gastric Banding Adjustment
Covered when medically necessary: HCPCS
Codes
Description
S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
Reoperation and Repeat Bariatric Surgery Covered when medically necessary:
CPT®* Codes
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
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy
43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with
reconstruction; with vagotomy
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
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
Bariatric Surgery for Type 2 Diabetes Mellitus
Experimental/Investigational/Unproven/Not Covered when performed solely for the treatment of type 2 diabetes mellitus when the BMI is < 35:
CPT®* Codes
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
43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, 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
43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, 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)
43850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy
43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with
reconstruction; with vagotomy
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
43887 Gastric restrictive procedure, open; removal of subcutaneous port component only
43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only
HCPCS Codes
Description
S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
Prophylactic Vena Cava Placement Covered when medically necessary:
CPT®* Codes
Description
37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and
interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
Other Procedures Performed in Conjunction with Bariatric Surgery
Not medically necessary/Not covered when performed in conjunction with a bariatric surgery in the absence of signs or symptoms of disease:
CPT®* Codes
Description
43234 Upper gastrointestinal endoscopy, simple primary examination (eg, with small diameter flexible endoscope) (separate procedure) (Code deleted 12/31/2013) 43332 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy,
except neonatal; without implantation of mesh or other prosthesis
43333 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis
43334 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis
43335 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis
43336 Repair, paraesophageal hiatal hernia, (including fundoplication), via
thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis
43337 Repair, paraesophageal hiatal hernia, (including fundoplication), via
prosthesis
47000 Biopsy of liver, needle; percutaneous
47001 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure)
47562 Laparoscopy, surgical; cholecystectomy
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 47600 Cholecystectomy;
47605 Cholecystectomy; with cholangiography
47610 Cholecystectomy with exploration of common duct;
*Current Procedural Terminology (CPT®) ©2013 American Medical Association: Chicago, IL.