General Surgery Coding Alert

Code 43846 involves partitioning the stomach (usually with staples) and connecting the small intestine to the proximal stomach. Commonly known as stomach stapling, this procedure allows food to bypass most of the stomach.

Code 43847 involves rerouting of the small bowel to limit food absorption and is used to describe services that may not have been as prevalent when the code was developed, such as biliary pancreatic diversion (when the bile ducts and pancreatic ducts are reattached to the ileum so digestion of fats is significantly delayed). This procedure is often performed with a near-total gastrectomy and Roux-en-Y intestinal anastomosis with a long roux limb, which is coded 43621 (Gastrectomy, total; with Roux-en-Y reconstruction). The small bowel reconstruction and biliary pancreatic diversion is reported using 43847.

Code 43848 (Revision of gastric restrictive procedure for morbid obesity [separate procedure]) is reported when the surgeon has to operate again on a patient who has had a previous gastric restrictive procedure (for example, stomach banding or stomach stapling). Typically, the surgeon mobilizes the stomach and then performs 43846 or 43847. Complications, such as slipped bands from a banded gastro-plasty, are dealt with during the same session.

In addition to evidence of obesity-related conditions, carriers may also want evidence that the patient has an established history of unsuccessful dieting attempts. They may even require that the patient undergo a psychiatric evaluation to determine that he or she does not have the motivation to attempt to lose weight without surgical intervention. The patient's dieting history and, if necessary, the psychiatrist's findings regarding the patient's mental status must be documented in the medical record.

Other procedures performed in conjunction with bariatric surgery, such as a total or partial gastrectomy, should be clearly noted in the surgeon's operative report.

If bariatric surgery is performed on an obese patient who does not have documented comorbidities, the patient should sign an advance beneficiary notice (ABN) waiver on the understanding that Medicare (or a private payer) may not cover the service and that out-of-pocket payment may be required.

Surgeons may perform a cholecystectomy (47600) and/or appendectomy (44950) during the same session.

These services may be payable separately, depending on the condition of the patient, Karl says. "If the surgeon opens the patient, determines that he or she has cholelithiasis (gallstones) and performs a cholecystectomy, 47600 may be billed separately," she says.

The same holds true for appendectomy: If a surgeon discovers an inflamed appendix, the appendectomy can be billed separately.

However, surgeons often perform appendectomy and cholecystectomy on a bariatric surgery patient whose digestive system has been dramatically rearranged, Bucknam adds. "If something starts to hurt, the surgeon wants to rule out appendicitis and gallstones. In such cases, both procedures are incidental to the gastric bypass and should not be billed separately."

If a cholecystectomy is performed because the patient has cholelithiasis and the appendix is removed merely as a preventive measure, only 47600 should be billed, Bucknam adds. On the other hand, if the appendix appears "abnormal" (with scarring and/or old inflammatory changes, for example), it is appropriate to report the appendectomy separately.

"It may be easier to get paid if you let your carriers know that you are performing bariatric surgery and are expecting patients from a wide geographic area," Bucknam says, noting that Blue Cross Blue Shield of Nebraska stopped requiring preauthorizations for bariatric surgery once the insurer became more familiar with the procedures and the reasons they are performed.