CMS Pub. 100-04, ch. 32, § 150.3

Conditions Related to Morbid Obesity (A/MACs only)

(Rev. 12683 Issued: 06-13-24; Effective: 01-01-20; Implementation: 07-15-24)

Covered ICD Procedure Codes

For services on or after October 1, 2015, the following independent ICD-10 procedure codes are

covered for bariatric surgery:

0D16479

Bypass Stomach to Duodenum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1647A

Bypass Stomach to Jejunum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1647B

Bypass Stomach to Ileum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1647L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D164J9

Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D164JA

Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D164JB Bypass Stomach to Ileum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D164JL

Bypass Stomach to Transverse Colon with Synthetic Substitute,

Percutaneous Endoscopic Approach

0D164K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D164KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D164KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D164KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue

Substitute, Percutaneous Endoscopic Approach

0D164Z9 Bypass Stomach to Duodenum, Percutaneous Endoscopic Approach

0D164ZA

Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach

0D164ZB

Bypass Stomach to Ileum, Percutaneous Endoscopic Approach

0D164ZL Bypass Stomach to Transverse Colon, Percutaneous Endoscopic

Approach

0D16079 Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open

Approach

0D1607A

Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open

Approach

0D1607B

Bypass Stomach to Ileum with Autologous Tissue Substitute, Open

Approach

0D1607L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute,

Open Approach

0D160J9

Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach

0D160JA

Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach

0D160JB

Bypass Stomach to Ileum with Synthetic Substitute, Open Approach

0D160JL

Bypass Stomach to Transverse Colon with Synthetic Substitute, Open

Approach

0D160K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute,

Open Approach

0D160KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute,

Open Approach

0D160KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Open

Approach

0D160KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue

Substitute, Open Approach

0D160Z9

Bypass Stomach to Duodenum, Open Approach

0D160ZA

Bypass Stomach to Jejunum, Open Approach

0D160ZB

Bypass Stomach to Ileum, Open Approach

0D160ZL

Bypass Stomach to Transverse Colon, Open Approach

0D16879 Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1687A

Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1687B

Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural

or Artificial Opening Endoscopic

0D1687L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute,

Via Natural or Artificial Opening Endoscopic

0D168J9

Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D168JA

Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D168JB

Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D168JL

Bypass Stomach to Transverse Colon with Synthetic Substitute, Via

Natural or Artificial Opening Endoscopic

0D168K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute,

Via Natural or Artificial Opening Endoscopic

0D168KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D168KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D168KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue

Substitute, Via Natural or Artificial Opening Endoscopic

0D168Z9

Bypass Stomach to Duodenum, Via Natural or Artificial Opening

Endoscopic

0D168ZA

Bypass Stomach to Jejunum, Via Natural or Artificial Opening

Endoscopic

0D168ZB Bypass Stomach to Ileum, Via Natural or Artificial Opening Endoscopic

0D168ZL

0DV64CZ

Bypass Stomach to Transverse Colon, Via Natural or Artificial Opening

Endoscopic

Restriction of Stomach with Extraluminal Device, Percutaneous

Endoscopic Approach

To describe either laparoscopic or open BPD with DS or GRDS, one code from each of the following three

groups must be on the claim:

Group 1:

0DB60Z3 Excision of Stomach, Open Approach, Vertical

0DB60ZZ Excision of Stomach, Open Approach

0DB63Z3 Excision of Stomach, Percutaneous Approach, Vertical

0DB63ZZ Excision of Stomach, Percutaneous Approach

0DB67Z3 Excision of Stomach, Via Natural or Artificial Opening, Vertical

0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening

0DB68Z3 Excision of Stomach, Via Natural or Artificial Opening Endoscopic, Vertical

Group 2:

(Note: One code from A-C below is required for a correct equivalent)

0DB80ZZ Excision of Small Intestine, Open Approach – A

0DB84ZZ Excision of Small Intestine, Perc Endo Approach – A (Effective 01-01-20)

0DB90ZZ Excision of Duodenum, Open Approach – A

0DB93ZZ Excision of Duodenum, Percutaneous Approach – A (Effective 01-01-20)

0DBB0ZZ Excision of Ileum, Open Approach – A

0DBB3ZZ Excision of Ileum, Percutaneous Approach – A (Effective 01-01-20)

0D160ZB Bypass Stomach to Ileum, Open Approach – B

0D164ZB Bypass Stomach to Ileum, Percutaneous Endoscopic Approach – B (Effective

01-01-20)

0F190Z3 Bypass Common Bile Duct to Duodenum, Open Approach – C

0F194Z3 Bypass Common Bile Duct to Duodenum, Perc Endo Approach – C (Effective

01-01-20)

Group 3:

0D19079

Bypass Duodenum to Duodenum with Autologous Tissue Substitute,

Open Approach

0D1907A

Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Open

Approach

0D1907B

Bypass Duodenum to Ileum with Autologous Tissue Substitute, Open

Approach

0D190J9

Bypass Duodenum to Duodenum with Synthetic Substitute, Open

Approach

0D190JA Bypass Duodenum to Jejunum with Synthetic Substitute, Open Approach

0D190JB Bypass Duodenum to Ileum with Synthetic Substitute, Open Approach

0D190K9

Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute,

Open Approach

0D190KA

Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute,

Open Approach

0D190KB

Bypass Duodenum to Ileum with Non-autologous Tissue Substitute, Open

Approach

0D190Z9

Bypass Duodenum to Duodenum, Open Approach

0D190ZA Bypass Duodenum to Jejunum, Open Approach

0D190ZB

Bypass Duodenum to Ileum, Open Approach

0D19479

Bypass Duodenum to Duodenum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1947A

Bypass Duodenum to Jejunum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1947B

Bypass Duodenum to Ileum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D194J9

Bypass Duodenum to Duodenum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D194JA

Bypass Duodenum to Jejunum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D194JB

Bypass Duodenum to Ileum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D194K9

Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D194KA Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D194KB

Bypass Duodenum to Ileum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D194Z9

Bypass Duodenum to Duodenum, Percutaneous Endoscopic Approach

0D194ZA

Bypass Duodenum to Jejunum, Percutaneous Endoscopic Approach

0D194ZB

Bypass Duodenum to Ileum, Percutaneous Endoscopic Approach

0D19879

Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1987A

Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1987B

Bypass Duodenum to Ileum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D198J9

Bypass Duodenum to Duodenum with Synthetic Substitute, Via Natural

or Artificial Opening Endoscopic

0D198JA

Bypass Duodenum to Jejunum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D198JB

Bypass Duodenum to Ileum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D198K9

Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute,

Via Natural or Artificial Opening Endoscopic

0D198KA

Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute,

Via Natural or Artificial Opening Endoscopic

0D198KB

Bypass Duodenum to Ileum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D198Z9

Bypass Duodenum to Duodenum, Via Natural or Artificial Opening

Endoscopic

0D198ZA

Bypass Duodenum to Jejunum, Via Natural or Artificial Opening

Endoscopic

0D198ZB

Bypass Duodenum to Ileum, Via Natural or Artificial Opening

Endoscopic

0D1A07A

Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Open

Approach

0D1A07B

Bypass Jejunum to Ileum with Autologous Tissue Substitute, Open

Approach

0D1A0JA Bypass Jejunum to Jejunum with Synthetic Substitute, Open Approach

0D1A0JB

Bypass Jejunum to Ileum with Synthetic Substitute, Open Approach

0D1A0KA

Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Open

Approach

0D1A0KB

Bypass Jejunum to Ileum with Non-autologous Tissue Substitute, Open

Approach

0D1A0ZA Bypass Jejunum to Jejunum, Open Approach

0D1A0ZB

Bypass Jejunum to Ileum, Open Approach

0D1A47A

Bypass Jejunum to Jejunum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1A47B

Bypass Jejunum to Ileum with Autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1A4JA

Bypass Jejunum to Jejunum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D1A4JB

Bypass Jejunum to Ileum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D1A4KA

Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1A4KB

Bypass Jejunum to Ileum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1A4ZA

Bypass Jejunum to Jejunum, Percutaneous Endoscopic Approach

0D1A4ZB

Bypass Jejunum to Ileum, Percutaneous Endoscopic Approach

0D1A87A

Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1A87B

Bypass Jejunum to Ileum with Autologous Tissue Substitute, Via Natural

or Artificial Opening Endoscopic

0D1A8JA

Bypass Jejunum to Jejunum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D1A8JB

Bypass Jejunum to Ileum with Synthetic Substitute, Via Natural or

Artificial Opening Endoscopic

0D1A8KA

Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1A8KB

Bypass Jejunum to Ileum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1A8ZA

Bypass Jejunum to Jejunum, Via Natural or Artificial Opening

Endoscopic

0D1A8ZB Bypass Jejunum to Ileum, Via Natural or Artificial Opening Endoscopic

0D1A8ZH

Bypass Jejunum to Cecum, Via Natural or Artificial Opening Endoscopic

0D1B07B

Bypass Ileum to Ileum with Autologous Tissue Substitute, Open

Approach

0D1B0JB Bypass Ileum to Ileum with Synthetic Substitute, Open Approach

0D1B0KB

Bypass Ileum to Ileum with Non-autologous Tissue Substitute, Open

Approach

0D1B0ZB

Bypass Ileum to Ileum, Open Approach

0D1B47B

Bypass Ileum to Ileum with Autologous Tissue Substitute, Percutaneous

Endoscopic Approach

0D1B4JB

Bypass Ileum to Ileum with Synthetic Substitute, Percutaneous

Endoscopic Approach

0D1B4KB

Bypass Ileum to Ileum with Non-autologous Tissue Substitute,

Percutaneous Endoscopic Approach

0D1B4ZB

Bypass Ileum to Ileum, Percutaneous Endoscopic Approach

0D1B87B

Bypass Ileum to Ileum with Autologous Tissue Substitute, Via Natural or

Artificial Opening Endoscopic

0D1B8JB

Bypass Ileum to Ileum with Synthetic Substitute, Via Natural or Artificial

Opening Endoscopic

0D1B8KB Bypass Ileum to Ileum with Non-autologous Tissue Substitute, Via

Natural or Artificial Opening Endoscopic

0D1B8ZB

Bypass Ileum to Ileum, Via Natural or Artificial Opening Endoscopic

0D1B8ZH

Bypass Ileum to Cecum, Via Natural or Artificial Opening Endoscopic

NOTE: There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient

setting. For either approach, one code from each of the above three groups must appear on the claim to be

covered.

Effective October 1, 2015, the following ICD-10 procedure code is covered for bariatric surgery at

contractor discretion:

0DB64Z3 Excision of stomach, percutaneous endoscopic approach, vertical.