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. Let’s 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.
- 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 payer’s coverage criteria.
- 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
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
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)
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
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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@legionhealthcaresolutions.com