Covered Bariatric Surgery Procedures

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 20th, 2015

Covered Bariatric Surgery Procedures

Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity.

The patient must have a body-mass index (BMI) 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility. A list of approved facilities may be found at

http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage.

Open Roux-en-Y gastric bypass (RYGBP).

Laparoscopic Roux-en-Y gastric bypass (RYGBP).

Laparoscopic adjustable gastric banding (LAGB).

Open biliopancreatic diversion with duodenal switch (BPD/DS).

Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).

Laparoscopic sleeve gastrectomy.

(Effective June 27, 2012, covered at contractor’s discretion.)150.2 -HCPCS Procedure Codes for Bariatric Surgery (Rev.2641, Issued: 01-29-13, Effective: 06-27-12, Implementation: 02-28-13)

 

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

150.3 -ICD-9 Procedure Codes for Bariatric Surgery (FIs only)

(Rev.2641, Issued: 01-29-13, Effective: 06-27-12, Implementation: 02-28-13)

 

A. Covered ICD Procedure Codes

For services on or after February 21, 2006, the following ICD-9 procedure codes are covered for bariatric surgery:

44.38 -Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or

44.39 -Other gastroenterostomy (open Roux-en-Y), or

44.95 -Laparoscopic gastric restrictive procedure (laparoscopic adjustable gastric band and port insertion),

or

To describe either laparoscopic or open BPD with DS, all three following codes must be on the claim:

43.89 -Other partial gastrectomy, and

45.51 -Isolation of segment of small intestine, and

45.91 -Small to small intestinal anastomosis.

NOTE:

There is no distinction between open and laparoscopic BPD with DS for the inpatient setting. For either approach, all three codes must appear on the claim to be covered.

Effective June 27, 2012, the following ICD-9 procedure code is covered for bariatric surgery:

43.82 -Laparoscopic sleeve gastrectomy covered at contractor’s discretion 150.5 –ICD-9 Diagnosis Codes or BMI ≥35 (Rev.2641, Issued: 01-29-13, Effective: 06-27-12, Implementation: 02-28-13)

The following ICD-9 diagnosis codes identify BMI 35:

V85.35 -Body Mass Index 35.0-35.9, adult

V85.36 -Body Mass Index 36.0-36.9, adult

V85.37 -Body Mass Index 37.0-37.9, adult

V85.38 -Body Mass Index 38.0-38.9, adult

V85.39 -Body Mass Index 39.0-39.9, adult

V85.41-Body Mass Index 40.0-44.9, adult

V85.42 -Body Mass Index 45.0-49.9, adult

V85.43 -Body Mass Index 50.0-59.9, adult

V85.44 -Body Mass Index 60.0-69.9, adult

V85.45 -Body Mass Index 70.0 and over, adult

 

The following ICD-10 diagnosis codes identify BMI 35:

Z6835-Body Mass Index 35.0-35.9, adult

Z6836 -Body Mass Index 36.0-36.9, adult

Z6837 -Body Mass Index 37.0-37.9, adult

Z6838 -Body Mass Index 38.0-38.9, adult

Z6839 -Body Mass Index 39.0-39.9, adult

Z6841 -Body Mass Index 40.0-44.9, adult

Z6842 -Body Mass Index 45.0-49.9, adult

Z6843-Body Mass Index 50.0-59.9, adult

Z6844-Body Mass Index 60.0-69.9, adult

Z6845-Body Mass Index 70.0 and over, adult

 

150.6 -Claims Guidance for Payment

(Rev.2641, Issued: 01-29-13, Effective: 06-27-12, Implementation: 2-28-13)

 

A. Covered Bariatric Surgery Procedures

Contractors shall process covered bariatric surgery claims as follows:

1. Identify bariatric surgery claims.

Contractors identify inpatient bariatric surgery claims by the presence of ICD-9-CM diagnosis code 278.01

(see ICD-10 equivilent in section 150.5) as the primary diagnosis (for morbid obesity) and one of the

covered ICD-9-CM procedure codes listed in §150.3.

Contractors identify practitioner bariatric surgery claims by the presence of ICD-9-CM diagnosis code 278.01(ICD-10 equivalentE66.01)as the primary diagnosis for morbid obesity) and one of the covered HCPCS procedure codes listed in §150.2.

 

2. Perform facility certification validation for all bariatric surgery claims on a pre-pay basis. A list of approved facilities may be found at: http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage.

 

3. Review bariatric surgery claims data and determine whether a pre-or post-pay sample of bariatric surgery claims need further review to assure that the beneficiary has a BMI ≥35 (V85.35 -V85.45) (see ICD-10 equivilents above n section 150.5), and at least one co-morbidity related to obesity.

 

The carrier/FI/A/B MAC medical director may define the appropriate method for addressing the obesity-related co-morbid requirement. NOTE: If ICD-9-CM diagnosis code 278.01 is present, but a covered procedure code (listed in §150.2 or §150.3) is/are not present, the claim is not for bariatric surgery and should be processed under normal procedures.

References:

Covered Bariatric Surgery Procedures. (2015, August 20). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/covered-bariatric-surgery-procedures-26641.html

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