Everything You Should Know while Billing for Bariatric Surgery

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Everything You Should Know while Billing for
Bariatric Surgery
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Everything You Should Know while Billing for
Bariatric Surgery

• Basics of Bariatric Surgery
• Bariatric surgery procedures are performed to
  treat comorbid conditions associated with morbid
  obesity. Two types of surgical procedures are
  employed. Malabsorptive procedures divert food
  from the stomach to a lower part of the digestive
  tract where the normal mixing of digestive fluids
  and absorption of nutrients cannot occur.
  Restrictive procedures restrict the size of the
  stomach and decrease intake. Surgery can combine
  both types of procedures.Bariatric procedures are
  performed for patients that have a diagnosis of
  obesity. While patients typically have associated
  comorbidities that should also be coded and
  reported, obesity remains the primary reason for
  the procedure. Payers may also require that a
  specific BMI be reported to meet coverage
  criteria. ICD-10-CM also provides codes
  specifically for complications of bariatric
  procedures. Lets understand information required
  while billing for bariatric surgery.
• Medicare Coverage for Bariatric Surgery
• While billing traditional Medicare, refer to
  national coverage determination for bariatric
  surgery. Medicare Advantage plans are required to
  cover at least what is covered by Traditional
  Medicare. Medicare Advantage plan administrators
  may have policies and additional requirements
  such as prior authorization.
• Open and laparoscopic Roux-en-Y gastric bypass
  (RYGBP), open and laparoscopic Biliopancreatic
  Diversion with Duodenal Switch (BPD/DS) or
  Gastric Reduction Duodenal Switch (BPD/GRDS), and
  laparoscopic adjustable gastric banding (LAGB)
  are covered for Medicare beneficiaries who have a
  body-mass index 35, have at least one
  co-morbidity related to obesity, and have been
  previously unsuccessful with medical treatment
  for obesity.

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Everything You Should Know while Billing for
Bariatric Surgery

• For Medicare, treatments for obesity alone remain
  non-covered. Supplemented fasting is not covered
  under the Medicare program as a general treatment
  for obesity.
• Medicare Administrative Contractors (MACs) acting
  within their respective jurisdictions may
  determine coverage of stand-alone laparoscopic
  sleeve gastrectomy (LSG) for the treatment of
  co-morbid conditions related to obesity in
  Medicare beneficiaries only when all of the
  following conditions are satisfied.
• The beneficiary has a body-mass index (BMI) 35
  kg/m2,
• The beneficiary has at least one co-morbidity
  related to obesity, and,
• The beneficiary has been previously unsuccessful
  with medical treatment for obesity.
• Other Guidelines while Billing for Bariatric
  Surgery
• Commercial insurance carriers typically determine
  coverage for procedures based on applicable
  medical policies. Prior authorization may be
  required. There may be plan specific coverage
  limitations.
• To avoid claim denials, use payer
  websites/provider portal to ensure latest
  coverage and submission requirements are
  followed. Also assign a staff member to
  coordinate all prior authorizations.
• Ensure submission of clinical information is
  accurate and reflects requirements within the
  medical policy.
• Relevant medical history, physical examination,
  and results of pertinent diagnostic tests or
  procedures may be required.
• Consider including a clear and concise letter of
  medical necessity to summarize how the patient
  has met the payers coverage criteria.

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Everything You Should Know while Billing for
Bariatric Surgery

• Submit information and maintain record of
  authorization review progress until a coverage
  decision is made. The medical record must support
  the medical necessity of all procedures being
  performed.
• Applicable HCPCS II Codes
• S2900 Surgical techniques requiring use of
  robotic surgical system (list separately in
  addition to code for primary procedure)
• S2083 Adjustment of gastric band diameter via
  subcutaneous port by injection or aspiration of
  saline
• A4649 Surgical supply miscellaneous
• Level II HCPCS codes are primarily used to report
  supplies, drugs and implants that are not
  reported by a CPT code. HCPCS codes are reported
  by the physician, hospital or DME provider that
  purchased the item, device, or supply. Different
  insurance carriers may have different payment
  methods for these items.
• Applicable CPT Codes
• Gastric Bypass, Laparoscopic
• 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

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Everything You Should Know while Billing for
Bariatric Surgery

• Gastric Band, Laparoscopic
• 43770 Laparoscopy, surgical, gastric restrictive
  procedure placement of adjustable gastric
  restrictive device (i.e., gastric band and
  subcutaneous port components)
• Gastric Band, Revision and Removal of Band,
  Laparoscopic
• 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
• Gastric Band, Revision and Removal of Port
• 43887 Gastric restrictive procedure, open
  removal of subcutaneous port component only
• 43888 Gastric restrictive procedure, open
  removal and replacement of subcutaneous port
  component only

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Everything You Should Know while Billing for
Bariatric Surgery

• Sleeve Gastrectomy
• 43775 Laparoscopy, surgical, gastric restrictive
  procedure longitudinal gastrectomy (ie, sleeve
  gastrectomy)
• 43842 Gastric restrictive procedure, without
  gastric bypass, for morbid obesity
  vertical-banded gastroplasty
• Biliopancreatic Diversion without Duodenal Switch
• 43632 Gastrectomy, partial, distal with
  gastrojejunostomy
• Biliopancreatic Diversion with Duodenal Switch
• 43845 Gastric restrictive procedure with partial
  gastrectomy, pylorus-preserving duodenoilesostomy
  and ileoileostomy (50 to 100 com common channel)
  to limit absorption (biliopancreatic diversion
  with duodenal switch)
• Gastric Bypass, Open
• 43846 Gastric restrictive procedure, with
  gastric bypass for morbid obesity with short
  limb (150 cm or less) Roux-en-Y Gastroenterostomy
• Revision, Gastric Restrictive Procedure
• 43848 Revision, open, of gastric restrictive
  procedure for morbid obesity, other than
  adjustable gastric restrictive device (separate
  procedure)

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Everything You Should Know while Billing for
Bariatric Surgery

• Other Revision
• 43860 Laparoscopy, surgical, gastric restrictive
  procedure longitudinal gastrectomy (ie, sleeve
  gastrectomy)
• 43862 Gastric restrictive procedure, without
  gastric bypass, for morbid obesity
  vertical-banded gastroplasty
• Single Anastomosis Duodeno-ileal Bypass with
  Sleeve Gastrectomy (SADI-S)
• 43659 Gastric restrictive procedure, without
  gastric bypass, for morbid obesity other than
  vertical-banded gastroplasty
• 43999 Gastrectomy, partial, distal with
  gastrojejunostomy
• 44799 Gastric restrictive procedure with partial
  gastrectomy, pylorus-preserving duodenoilesostomy
  and ileoileostomy (50 to 100 com common channel)
  to limit absorption (biliopancreatic diversion
  with duodenal switch)
• 44238 Gastric restrictive procedure, with
  gastric bypass for morbid obesity with short
  limb (150 cm or less) Roux-en-Y gastroenterostomy
• CPT is a registered trademark of the American
  Medical Association.
• Legion Healthcare Solutions is a reliable medical
  billing company providing complete medical
  billing and coding services. We shared all
  necessary information required for billing for
  bariatric surgery. You are advised to refer
  patient insurance coverage and payer guidelines
  for detailed understanding. You can hire our
  billing and coding services to receive more
  insurance reimbursements while staying compliant
  with payer-specific and state-specific
  guidelines. To know more about billing and coding
  services, contact us at 727-475-1834 or email us
  at info_at_legionhealthcaresolutions.com

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