Medicare no longer requires facility certification for bariatric surgery

January 30th, 2014 - Scott Kraft
Categories:   Coding   National Coverage Determinations (NCD)  
0 Votes - Sign in to vote or comment.

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.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
CMS Expands Telehealth Again
October 20th, 2020 - Wyn Staheli, Director of Research
On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.
Significant COVID-19 Code Changes as of October 6
October 8th, 2020 - Wyn Staheli, Director of Research
Significan COVID-19 Code Changes as of October 6



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association