Billing and Coding: Bariatric Surgery Coverage

Background Coverage 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 Gastrectomy To 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 requirements d. 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 Codes For 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: 0DB64Z3 0DV64CZ 0D16479 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: 0D16079 0D1607A 0D1607B 0D1607L 0D160J9 0D160JA 0D160JB 0D160JL 0D160K9 0D160KA 0D160KB 0D160KL 0D160Z9 0D160ZA 0D160ZB 0D160ZL 0D16879 0D1687A 0D1687B 0D1687L 0D168J9 0D168JA 0D168JB 0D168JL 0D168K9 0D168KA 0D168KB 0D168KL 0D168Z9 0D168ZA 0D168ZB 0D168ZL 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: 0DB80ZZ 0DB90ZZ 0DBB0ZZ Group B: 0D160ZB Group C: 0F190Z3 Group 3: 0D19079 0D1907A 0D1907B 0D190J9 0D190JA 0D190JB 0D190K9 0D190KA 0D190KB 0D190Z9 0D190ZA 0D190ZB 0D19479 0D1947A 0D1947B 0D194J9 0D194JA 0D194JB 0D194K9 0D194KA 0D194KB 0D194Z9 0D194ZA 0D194ZB 0D19879 0D1987A 0D1987B 0D198J9 0D198JA 0D198JB 0D198K9 0D198KA 0D198KB 0D198Z9 0D198ZA 0D198ZB 0D1A07A 0D1A07B 0D1A0JA 0D1A0JB 0D1A0KA 0D1A0KB 0D1A0ZA 0D1A0ZB 0D1A47A 0D1A47B 0D1A4JA 0D1A4JB 0D1A4KA 0D1A4KB 0D1A4ZA 0D1A4ZB 0D1A87A 0D1A87B 0D1A8JA 0D1A8JB 0D1A8KA 0D1A8KB 0D1A8ZA 0D1A8ZB 0D1A8ZH 0D1B07B 0D1B0JB 0D1B0KB 0D1B0ZB 0D1B47B 0D1B4JB 0D1B4KB 0D1B4ZB 0D1B87B 0D1B8JB 0D1B8KB 0D1B8ZB 0D1B8ZH NOTE: There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered. Nationally Non-Covered Procedures For services on or after February 21, 2006, Medicare (CMS) has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01): • Open adjustable gastric banding (Billed with a Not Otherwise Classified (NOC) code) • Open sleeve gastrectomy; • Laparoscopic sleeve gastrectomy (prior to June 27, 2012); • Open and laparoscopic vertical banded gastroplasty; • Intestinal bypass surgery; and, • Gastric balloon for treatment of obesity.