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1 Local Coverage Article: Bariatric Surgery Coverage (A53026) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E California - Entire State Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E California - Northern Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E California - Southern Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E American Samoa Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E American Samoa Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E Nevada Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E Nevada Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E American Samoa California - Entire State Guam Hawaii Nevada Northern Mariana Islands Back to Top Article Information General Information Article ID A53026 Original ICD-9 Article ID A52803 Article Title Bariatric Surgery Coverage AMA CPT / ADA CDT / AHA NUBC Copyright Statement Original Article Effective Date 10/01/2015 Revision Effective Date 10/01/2016 Revision Ending Date N/A Retirement Date N/A Printed on 11/28/2016. Page 1 of 22

2 CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Article Guidance Article Text: Background Coverage of bariatric surgery is described in the Internet Only Manual (IOM) Medicare National Coverage Determinations Manual, Publication , Section Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity and Medicare Claims Processing Manual, Publication , Chapter 32, Section 150. The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination As of the effective date of this article revision Medicare (CMS) has established by NCD that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity. 1. Roux-en-Y Gastric Bypass (RYGBP) 2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS) 3. Laparoscopic Adjustable Gastric Banding (AGB) 4. Laparoscopic Sleeve Gastrectomy To be eligible for bariatric surgery the patient must have a body-mass index (BMI) &# , and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant. Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD: 1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patient s weight and BMI, current dietary regimen and physical activity (e.g. exercise program). Printed on 11/28/2016. Page 2 of 22

3 2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. 3. A thorough multidisciplinary evaluation is required within the previous six months which includes ALL of the following: a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiary s primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgery c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirements d. a nutritional evaluation by a physician or registered dietician. Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZ Nationally Covered Inpatient Facility ICD-10-CM Procedure Codes For services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery: Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes: 0D D1647A 0D1647B 0D1647L 0D164J9 0D164JA 0D164JB 0D164JL 0D164K9 0D164KA 0D164KB 0D164KL 0D164Z9 0D164ZA 0D164ZB 0D164ZL Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes: 0D D1607A 0D1607B 0D1607L 0D160J9 0D160JA 0D160JB 0D160JL 0D160K9 0D160KA 0D160KB 0D160KL 0D160Z9 0D160ZA 0D160ZB 0D160ZL 0D D1687A 0D1687B 0D1687L 0D168J9 0D168JA 0D168JB 0D168JL 0D168K9 0D168KA 0D168KB Printed on 11/28/2016. Page 3 of 22

4 0D168KL 0D168Z9 0D168ZA 0D168ZB 0D168ZL 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 0DB60ZZ 0DB63Z3 0DB63ZZ 0DB67Z3 0DB67ZZ 0DB68Z3 Group 2: One code from Groups A-C below is required. Group A: 0DB80ZZ 0DB90ZZ 0DBB0ZZ Group B: 0D160ZB Group C: 0F190Z3 Group 3: 0D D1907A 0D1907B 0D190J9 0D190JA 0D190JB 0D190K9 0D190KA 0D190KB 0D190Z9 0D190ZA 0D190ZB 0D D1947A 0D1947B 0D194J9 0D194JA 0D194JB 0D194K9 0D194KA 0D194KB 0D194Z9 0D194ZA 0D194ZB 0D D1987A 0D1987B 0D198J9 0D198JA 0D198JB 0D198K9 0D198KA 0D198KB 0D198Z9 Printed on 11/28/2016. Page 4 of 22

5 0D198ZA 0D198ZB 0D1A07A 0D1A07B 0D1A0JA 0D1A0JB 0D1A0KA 0D1A0KB 0D1A0ZA 0D1A0ZB 0D1A47A 0D1A47B 0D1A47B 0D1A4JA 0D1A4JB 0D1A4KA 0D1A4KB 0D1A4ZA 0D1A4ZB 0D1A87A 0D1A87B 0D1A8JA 0D1A8JB 0D1A8KA 0D1A8KB 0D1A8ZA 0D1A8ZB 0D1A8ZH 0D1B07B 0D1B0JB 0D1B0KB 0D1B0ZB 0D1B47B 0D1B4JB 0D1B4KB 0D1B4ZB 0D1B87B 0D1B8JB 0D1B8KB 0D1B8ZB 0D1B8ZH 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. Nationally Non-Covered Procedures For services on or after February 21, 2006, Medicare (CMS) has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01): Open adjustable gastric banding (Billed with a Not Otherwise Classified (NOC) code) Open sleeve gastrectomy; Laparoscopic sleeve gastrectomy (prior to June 27, 2012); Open and laparoscopic vertical banded gastroplasty; Intestinal bypass surgery; and, Gastric balloon for treatment of obesity. Back to Top Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply Printed on 11/28/2016. Page 5 of 22

6 equally to all claims. Bill Type Code Bill Type 011x Hospital Inpatient (Including Medicare Part A) Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: Nationally Covered CPT Procedure Codes For services on or after February 21, 2006, the following CPT procedure codes are covered for bariatric surgery: Group 1 Codes: Group 1 CPT/HCPCS Code Group 1 CPT/HCPCS Code LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) 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) GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION Group 2 Paragraph: Noridian Local Coverage for Laparoscopic Sleeve Gastrectomy Group 2 Codes: Group 2 CPT/HCPCS Code Group 2 CPT/HCPCS Code LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY) ICD-10 Codes that are Covered Group 1 Paragraph: To ensure proper claims processing, claims must contain the following information: CPT or ICD-10-PCS 0DV64CZ The ICD-10-CM code E66.01 (Morbid (severe) obesity due to excess calories), An ICD-10-CM code reflecting the co-morbid condition necessitating the procedure (e.g., diabetes, hypertension, cardiac or respiratory diseases) and An ICD-10-CM code describing the patient s BMI. Acceptable ICD-10-CM codes describing the co-morbid condition and supporting medical necessity for bariatric Printed on 11/28/2016. Page 6 of 22

7 surgical procedures are: Group 1 Codes: ICD-10 Codes that are covered Information Table Code Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC) E08.00 E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication E Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular E edema Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E macular edema, right Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E macular edema, left Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with E macular edema, Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E macular edema, right Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E macular edema, left Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without E macular edema, Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with E macular edema, right Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with E macular edema, left Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with E macular edema, Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E without macular edema, right Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E without macular edema, left Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E without macular edema, Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E macular edema, right Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E macular edema, left Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with E macular edema, Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without E macular edema, right Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without E macular edema, left Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without E macular edema, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E edema, right Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E edema, left Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular E edema, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E retinal detachment involving the macula, right Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E retinal detachment involving the macula, left Printed on 11/28/2016. Page 7 of 22

8 Code E Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E retinal detachment not involving the macula, right Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E retinal detachment not involving the macula, left Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction E retinal detachment not involving the macula, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E traction retinal detachment and rhegmatogenous retinal detachment, right Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E traction retinal detachment and rhegmatogenous retinal detachment, left Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined E traction retinal detachment and rhegmatogenous retinal detachment, E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left E Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E edema, right Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E edema, left Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular E edema, E08.36 Diabetes mellitus due to underlying condition with diabetic cataract Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following E08.37X1 treatment, right Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following E08.37X2 treatment, left Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following E08.37X3 treatment, E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E Diabetes mellitus due to underlying condition with other diabetic arthropathy E Diabetes mellitus due to underlying condition with diabetic dermatitis E Diabetes mellitus due to underlying condition with foot ulcer E Diabetes mellitus due to underlying condition with other skin ulcer E Diabetes mellitus due to underlying condition with other skin complications E Diabetes mellitus due to underlying condition with periodontal disease E Diabetes mellitus due to underlying condition with other oral complications E Diabetes mellitus due to underlying condition with hypoglycemia with coma E Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition without complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy Printed on 11/28/2016. Page 8 of 22

9 Code E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular E edema Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E edema, right Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E edema, left Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E edema, Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E macular edema, right Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E macular edema, left Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without E macular edema, Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E macular edema, right Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E macular edema, left Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with E macular edema, Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without E macular edema, right Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without E macular edema, left Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without E macular edema, Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E macular edema, right Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E macular edema, left Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with E macular edema, Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E macular edema, right Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E macular edema, left Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without E macular edema, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, E right Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, E left Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, E Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment involving the macula, right Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment involving the macula, left Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment involving the macula, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment not involving the macula, right Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment not involving the macula, left Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal E detachment not involving the macula, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E traction retinal detachment and rhegmatogenous retinal detachment, right E Printed on 11/28/2016. Page 9 of 22

10 Code Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined E traction retinal detachment and rhegmatogenous retinal detachment, E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left E Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E edema, right Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E edema, left Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular E edema, E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, E09.37X1 right Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, E09.37X2 left Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, E09.37X3 E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, E09.40 unspecified Drug or chemical induced diabetes mellitus with neurological complications with diabetic E09.41 mononeuropathy Drug or chemical induced diabetes mellitus with neurological complications with diabetic E09.42 polyneuropathy Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic E09.43 (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy Drug or chemical induced diabetes mellitus with neurological complications with other diabetic E09.49 neurological complication E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E Drug or chemical induced diabetes mellitus with other diabetic arthropathy E Drug or chemical induced diabetes mellitus with diabetic dermatitis E Drug or chemical induced diabetes mellitus with foot ulcer E Drug or chemical induced diabetes mellitus with other skin ulcer E Drug or chemical induced diabetes mellitus with other skin complications E Drug or chemical induced diabetes mellitus with periodontal disease E Drug or chemical induced diabetes mellitus with other oral complications E Drug or chemical induced diabetes mellitus with hypoglycemia with coma E Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complication E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus without complications E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Printed on 11/28/2016. Page 10 of 22

11 Code E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E right Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E left Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E right Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, right Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, left Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, right Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, left Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, right Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, left Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left E Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma E11.00 (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left Printed on 11/28/2016. Page 11 of 22

12 Code E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E right Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E left Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right E E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E right Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, E E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, right Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, left Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, right Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, left Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not E involving the macula, Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, right Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, left Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left E Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, Printed on 11/28/2016. Page 12 of 22

13 Code E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with other diabetic arthropathy E Type 2 diabetes mellitus with diabetic dermatitis E Type 2 diabetes mellitus with foot ulcer E Type 2 diabetes mellitus with other skin ulcer E Type 2 diabetes mellitus with other skin complications E Type 2 diabetes mellitus with periodontal disease E Type 2 diabetes mellitus with other oral complications E Type 2 diabetes mellitus with hypoglycemia with coma E Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E right Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E left Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E edema, right Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E edema, left Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E edema, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E edema, right Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E edema, left Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E edema, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E edema, right Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E edema, left Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular E edema, Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E right Printed on 11/28/2016. Page 13 of 22

14 Code E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, E Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E edema, right Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E edema, left Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E edema, E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left E Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, right Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, left Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E involving the macula, Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E not involving the macula, right Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E not involving the macula, left Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment E not involving the macula, Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, right Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, left Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal E detachment and rhegmatogenous retinal detachment, E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left E Other specified diabetes mellitus with stable proliferative diabetic retinopathy, Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left E Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, E E13.36 Other specified diabetes mellitus with diabetic cataract E13.37X1 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, right E13.37X2 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, left E13.37X3 Other specified diabetes mellitus with diabetic macular edema, resolved following treatment, E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E Other specified diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with other diabetic arthropathy E Other specified diabetes mellitus with diabetic dermatitis E Other specified diabetes mellitus with foot ulcer E Other specified diabetes mellitus with other skin ulcer E Other specified diabetes mellitus with other skin complications Printed on 11/28/2016. Page 14 of 22

15 Code E Other specified diabetes mellitus with periodontal disease E Other specified diabetes mellitus with other oral complications E Other specified diabetes mellitus with hypoglycemia with coma E Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E28.2 Polycystic ovarian syndrome E28.39 Other primary ovarian failure E28.8 Other ovarian dysfunction G47.30 Sleep apnea, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G93.2 Benign intracranial hypertension I10 Essential (primary) hypertension I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I15.2 Hypertension secondary to endocrine disorders I15.8 Other secondary hypertension I15.9 Secondary hypertension, unspecified I27.2 Other secondary pulmonary hypertension I27.89 Other specified pulmonary heart diseases I50.1 Left ventricular failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I67.4 Hypertensive encephalopathy I Varicose veins of right lower extremity with ulcer of thigh I Varicose veins of right lower extremity with ulcer of calf I Varicose veins of right lower extremity with ulcer of ankle I Varicose veins of right lower extremity with ulcer of heel and midfoot I Varicose veins of right lower extremity with ulcer other part of foot I Varicose veins of right lower extremity with ulcer other part of lower leg I Varicose veins of left lower extremity with ulcer of thigh I Varicose veins of left lower extremity with ulcer of calf I Varicose veins of left lower extremity with ulcer of ankle I Varicose veins of left lower extremity with ulcer of heel and midfoot I Varicose veins of left lower extremity with ulcer other part of foot I Varicose veins of left lower extremity with ulcer other part of lower leg I Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation I Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation I Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation Printed on 11/28/2016. Page 15 of 22

16 Code I Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation I Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of right lower extremity with both ulcer of thigh and inflammation I Varicose veins of right lower extremity with both ulcer of calf and inflammation I Varicose veins of right lower extremity with both ulcer of ankle and inflammation I Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of right lower extremity with both ulcer other part of foot and inflammation I Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of left lower extremity with both ulcer of thigh and inflammation I Varicose veins of left lower extremity with both ulcer of calf and inflammation I Varicose veins of left lower extremity with both ulcer of ankle and inflammation I Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of right lower extremities with pain I Varicose veins of left lower extremities with pain I Varicose veins of lower extremities with pain I Varicose veins of right lower extremities with other complications I Varicose veins of left lower extremities with other complications I Varicose veins of lower extremities with other complications K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis M Enteropathic arthropathies, right hip M Enteropathic arthropathies, left hip M Enteropathic arthropathies, right knee M Enteropathic arthropathies, left knee M Enteropathic arthropathies, right ankle and foot M Enteropathic arthropathies, left ankle and foot M07.68 Enteropathic arthropathies, vertebrae M Other specific arthropathies, not elsewhere classified, right hip M Other specific arthropathies, not elsewhere classified, left hip M Other specific arthropathies, not elsewhere classified, right knee M Other specific arthropathies, not elsewhere classified, left knee M Other specific arthropathies, not elsewhere classified, right ankle and foot M Other specific arthropathies, not elsewhere classified, left ankle and foot M16.0 Bilateral primary osteoarthritis of hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other secondary osteoarthritis of hip M16.7 Other unilateral secondary osteoarthritis of hip M17.0 Bilateral primary osteoarthritis of knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M Primary osteoarthritis, right ankle and foot M Primary osteoarthritis, left ankle and foot Printed on 11/28/2016. Page 16 of 22