Medicare no longer requires facility certification for bariatric surgery

January 30th, 2014 - Scott Kraft
Categories:   Coding   National Coverage Determinations (NCD)  
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Thanks to a recent tweak to Medicare policy, facilities are no longer required to be certified in order for bariatric surgery procedures to be covered, CMS announced in a recent transmittal modifying its National Coverage Determination (NCD) on the procedure. The change took effect September 24.

Left unchanged in the NCD review were the required coverage conditions for bariatric surgery. Before payment can be made for bariatric surgery, Medicare requires these three conditions to be in place:
  1. Patient has a body mass index of greater than or equal to 35
  2. Patient has at least one co-morbidity related to obesity
  3. Previous medical treatments for obesity have not been successful

Common comorbidities for morbid obesity include type 2 diabetes, coronary artery disease, hypertension, osteoarthritis of venous stasis disease.

Only certain types of bariatric surgeries are covered by Medicare – open and laparoscopic Roux-en-Y gastric bypass (RYGPB), laparoscopic adjustable gastric banding (LAGB) and open and laprascopic biliopancreatic diversion with duodenal switch (BPD/DS).

Here are the CPT® codes Medicare allows for bariatric surgery:
  • 43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
  • 43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847)
  • 43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)
  • 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).
  • 43847 - With small intestine reconstruction to limit absorption;

Here are the payable ICD-9 codes: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4; or 278.01.


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