Gastroenterology Coding Alert

Question: I heard that Medicare made some changes about diabetic patients' eligibility for bariatric surgery. Do we have to pay more attention to the patient's BMI?

Washington, D.C. Subscriber

Answer: Medicare did implement some new regulations for bariatric procedures for diabetic patients.

The rule: If your physician performs bariatric surgery procedures on a diabetic patient, you need to take note of the patient's body mass index (BMI) -- it could be your magic number in determining the patient's eligibility for Medicare payment, according to MLN Matters article MM6419, effective May 18.

Effective for any services performed on Feb. 12 or thereafter, the following three procedures are not covered for patients with type II diabetes (250.x0 or 250.x2) and a BMI under 35 (V85.0-V85.34):

• Open and laparoscopic Roux-en-Y gastric bypass (43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Rouxen-Y gastroenterostomy and 43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less])

• Laparoscopic adjustable gastric banding (43770, Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device [e.g., gastric band and subcutaneous port components] and 43773, ... removal and replacement of adjustable gastric restrictive device component only)

• Open and laparoscopic biliopancreatic diversion with duodenal switch (43845-43847, Gastric restrictive procedure with partial gastrectomy ... and 43645, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption).

The upside: CMS will cover these procedures in patients who have type II diabetes and a BMI of 35 or higher.

Visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6419.pdf  for more information.