CMS Pub. 100-04, ch. 32, § 150.2

A. Covered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric

surgery:

43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band

and subcutaneous port components).

43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y

gastroenterostomy (roux limb 150 cm or less).

43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report

43645 in conjunction with 49320, 43847.)

43845 - Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and

ileoieostomy (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. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.)

43847 - With small intestine reconstruction to limit absorption.

43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)

(Effective June 27, 2012, covered at contractor’s discretion.)

B. Non-Covered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are non-covered for bariatric

surgery:

43842 - Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty

NOC code 43999 used to bill for:

Laparoscopic vertical banded gastroplasty

Open sleeve gastrectomy

Laparoscopic sleeve gastrectomy (for contractor non-covered instances)

Open adjustable gastric banding