General Surgery Coding Alert

Avoid common pitfalls like coding based on supplier recommendations.

In Vol. 11, No. 6 of General Surgery Coding Alert, the You Be the Coder question and answer discussed how to report gastric band adjustments. Several readers wrote in to comment on the article and ask about alternate coding. Here our experts set the record straight on the best ways to report gastric band adjustments your surgeon performs.

Payer Preference Indicates When to Use S2083

To adjust a gastric band, the physician can inject or aspirate saline into an access port, which connects to the band, and effectively manipulate stomach size (and thus control appetite suppression, satiety, and weight loss).

Although there currently is no specific CPT code for this sort of adjustment of the gastric band, you may be able to report the procedure using S2083 (Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline) or 43999 (Unlisted procedure, stomach), experts say.

Consult your payer: Some payers will pay for S2083 and some will not, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Childrens University Medical Group Compliance Program. You need to contact your local payer to see which code you should use for gastric band adjustments, she stresses.

We are actually getting paid by all insurances except Medicare and IPA Renaissance (a.k.a. Texas Healthspring, a Medicare replacement), says Jennifer Reichle, CMC, with Coastal Surgical Group L.C., Houston, Tex. I also include the volume amount of the adjustment with the NDC # [National Drug Code] with every submission of S2083. Every once in a while UHC will request progress notes, and we send the office notes along with the patients adjustment log sheet and then they will pay, she adds.

We have been paid on the S2083 code by Independence Blue Cross, Aetna,Horizon BS of NJ, and Highmark Blue Shield. We are waiting on a UnitedHealthcare claim, which is more of a credentialing issue than the procedure code, says Judith L.DePalma, CMM, practice manager of Twin Rivers Surgical in Easton, Pa. The payment amount varies by payer, but ranges from $160-$278.

Pitfall #1: Be cautious following the coding advice of supply companies, such as gastric band suppliers. Often the codes the suppliers tell you to report are not the codes that your payers want you to report for the procedure. You need to follow payer guidelines, not supplier guidelines, in order to get paid.

Turn to 43999 for Some Payers

Some payers will not accept S codes. For example,Medicare does not accept the S2083 code, says DePalma.

For payers who do not accept the S codes, you should report 43999 for a saline adjustment, Bucknam says. I would only use code 43999 for saline adjustments of the lap band for payers that did not accept S2083, she explains.

Pitfall #2: Dont think just because 43999 falls in the surgery section of the CPT manual that you cannot use it to code gastric band adjustments, which may not be truly surgical procedures.

There are many services in the surgery chapter of CPT that would certainly be no more invasive than the lap band fill -- for example, 36416 for collection of blood by finger stick, says Bucknam.

Note: If your surgeon performed an actual surgical adjustment of the lap band (not an injection or aspiration of saline), you would code that procedure using 43771 (Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only), not 43999. CPT added 43771 in 2004, but this code does not describe gastric band adjustments (by saline injection or aspiration). Rather, this is a surgical procedure that involves laparoscopic manipulation of a gastric band placed during a previous procedure.

You Can Separately Report Guidance

If your surgeon has to use fluoroscopic guidance while performing the lap band adjustment, you can separately report that service. Appropriate codes could include 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) or 77002 (Fluoroscopic guidance for needle placement [e.g.. biopsy, aspiration,injection, localization device]), depending on the physicians documentation.

I can see no reason not to bill guidance if you need it, although these adjustments are usually done through a subcutaneous port, which one would expect to be palpable, Bucknam says. The reason for routine guidance is not obvious, although it might be appropriate for patients who need to lose a lot of weight or who have lost a lot of weight and have lots of extra skin to work through.

Check Global Period Before Billing Adjustments

When you are reporting lap band adjustments, be sure to check the documentation to see if the patient is still in the global period of the original procedure.

In the global: As noted in the original article in Vol.11, No. 6, if the patient is still within 90 days of the original surgery, adjustments fall within the global period for postoperative management and you cannot separately report the service. In other words, there is no separate new payment for staged adjustments that fall within the surgical global period.

You should include such adjustments to the gastric band by saline injection/aspiration as a standard postoperative component of 43770 (... 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).

CPT is clear about this guideline, stating Typical postoperative follow-up care & after gastric restriction using the adjustable gastric restrictive device includes subsequent restrictive device adjustment(s) through the postoperative period for the typical patient.

Although I am sure it is possible to get these services paid using a modifier (58 or 79), it is inappropriate and I would expect the insurer to ask for their money back on review, Bucknam cautions.

Out of the global: If the surgeon performs the adjustment outside of the global period, you can and should report the procedure using S2083 or 43999 as discussed above.