Gastroenterology Coding Alert

Question: Our physician performed bariatric surgery for an obese patient with coronary heart disease. We reported both E66.01 (Morbid [severe] obesity due to excess calories) and Z68.45 (BMI 70 or greater, adult), which have worked in the past. Can you explain what the problem is?

Codify Subscriber

Answer: It sounds like you’re most of the way there—you’ve reported the first two codes that prove medical necessity for this procedure—the high BMI and the morbid obesity. The only thing you appear to be missing is a comorbidity that justifies the surgery.

“The surgical management for the treatment of morbid obesity is considered reasonable and necessary for Medicare beneficiaries who have a BMI>35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity,” says Performant Recovery, the CMS recovery audit contractor (RAC) for two regions.

On Feb. 1, Performant approved bariatric surgery as a procedure that the RAC is actively auditing. Typically, when a RAC approves an issue, that means that it has been identified as a commonly-misbilled procedure, so you may not be the only one forgetting the additional code. As for payers reimbursing you in the past with these ICD-10 codes, it’s possible that some private payers do not require the comorbidities, but now that you’re billing Medicare, you need to use them.

Therefore, you must identify the additional issue your patient has which prompts the procedure. For example, if the patient has Type two diabetes with circulatory complications, you’ll report a code such as E11.51 (Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene). Your documentation must clearly demonstrate the fact that the patient has been unsuccessful in treating the obesity with non-surgical interventions. Describe the past medical treatments that the patient has tried in detail in the notes.