Billing and Coding: Bariatric Surgery Coverage

Medicare covers Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch (BPD/DS or BPD/GRDS), laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy when beneficiaries have BMI ≥35 with at least one obesity-related comorbidity, have documented failure of physician-supervised non-surgical weight-management (minimum 4 consecutive months within the prior 12 months), and have completed a multidisciplinary evaluation within the prior 6 months. Claims must include the specified ICD-10-PCS procedure codes (with a three-group code requirement for BPD/DS/GRDS) and omission of required documentation or performance of nationally non-covered procedures (e.g., open AGB, open sleeve gastrectomy, vertical banded gastroplasty, intestinal bypass, gastric balloon) will preclude coverage.

"Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatment..."