by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
June 9th, 2015
CMS has determined that the following procedures will be covered for beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, have been previously unsuccessful with medical treatment of obesity, and this medical information must be documented in the patient's medical record.
Submitted claims must have the following listed inclusions:
- One of the CPT codes listed above that reflects the procedure performed by the provider
- The ICD-9-CM 278.01, Morbid obesity listed as primary on the claim.
- An ICD-9-CM code reflecting the co-morbid condition necessitating the procedure (e.g., diabetes, hypertension, cardiac or respiratory diseases) from the long NAS listing below and listed as secondary on the claim.
- One of the following tertiary ICD-9-CM codes describing the BMI:
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).
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
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),
To describe either laparoscopic or open BPD with DS, all three following codes must be on the claim:
o 43.89 -Other partial gastrectomy, and
o 45.51 -Isolation of segment of small intestine, and
o 45.91 -Small to small intestinal anastomosis.
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: