Billing and Coding: Bariatric Surgery Coverage
A53028
BackgroundCoverage of bariatric surgery is described in the Internet Only Manual (IOM) Medicare National Coverage Determinations Manual, Publication 100-03, Section 100.1 Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity and Medicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 150. The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination 100.1. As of the effective date of this article revision Medicare (CMS) has established by NCD 100.1 that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity. 1. Roux-en-Y Gastric Bypass (RYGBP)2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS)3. Laparoscopic Adjustable Gastric Banding (AGB)4. Laparoscopic Sleeve GastrectomyTo be eligible for bariatric surgery the patient must have a body-mass index (BMI) ≥ 35, and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant.Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD:1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patient’s weight and BMI, current dietary regimen and physical activity (e.g. exercise program).2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.3. A thorough multidisciplinary evaluation is required within the previous six months which includes ALL of the following: a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s) b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiary’s primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgery c. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirementsd. a nutritional evaluation by a physician or registered dietician. Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZ Nationally Covered Inpatient Facility ICD-10-CM Procedure CodesFor services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery: Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes: 0DB64Z30DV64CZ0D16479 0D1647A 0D1647B 0D1647L 0D164J9 0D164JA 0D164JB 0D164JL 0D164K9 0D164KA 0D164KB 0D164KL 0D164Z9 0D164ZA 0D164ZB 0D164ZL Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes: 0D160790D1607A0D1607B0D1607L0D160J90D160JA0D160JB0D160JL0D160K90D160KA0D160KB0D160KL0D160Z90D160ZA0D160ZB0D160ZL0D168790D1687A0D1687B0D1687L0D168J90D168JA0D168JB0D168JL0D168K90D168KA0D168KB0D168KL0D168Z90D168ZA0D168ZB0D168ZL To describe either laparoscopic or open BPD with DS or GRDS, one code from each of the following three groups must be on the claim: Group 1:0DB60Z3 0DB60ZZ 0DB63Z3 0DB63ZZ 0DB67Z3 0DB67ZZ 0DB68Z3 Group 2:One code from Groups A-C below is required.Group A:<br