General Surgery Coding Alert

Look for co-morbid factors too.

If your surgeon wants to get paid for bariatric surgery, you need to cross all your "T's" and dot all your "I's." Medicare and other payers that follow CMS guidelines require lots of documentation -- and even certification -- to let you get the job done.

Document Obesity and Treatment

First, you'll need ICD-9 documentation of morbid obesity. "Based on the medical record, you should list the primary diagnosis as 278.01 (Morbid obesity), and a secondary diagnosis code from category V85 (Body Mass Index [BMI]) indicating a BMI greater than or equal to 35," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

In addition to documenting obesity, the medical record must also demonstrate that the patient has previously been unsuccessful with the medical treatment of obesity.

Add Co-Morbid Diagnoses

Obesity and failed treatment alone won't justify bariatric surgery for a Medicare beneficiary.

You must also show that the patient presents with at least one adverse health concern related to obesity. The following list gives you an idea of the diagnoses that might fit the bill:

• Hypertension -- such as 401.x (Essential hypertension)
• Type-II diabetes -- 250.xx (Diabetes mellitus) with fourth digits 0 (type II or unspecified type, not stated as uncontrolled) or 2 (type II or unspecified type, uncontrolled)
• Coronary heart disease -- such as 414.0 (Coronary atherosclerosis)
• Stroke -- such as 431 (Intracerebral hemorrhage).

Other comorbid conditions include gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers.

Only Qualified/Certified Surgeons Need Apply

Your surgeon must meet one more qualification if you expect Medicare coverage for bariatric surgery.

CMS has determined that the benefit of bariatric surgery "can only be assured in facilities that do large numbers of these procedures performed by highly qualified surgeons." Specifically, such facilities must obtain certification from either the American College of Surgeons or the American Society of Bariatric Surgery.