General Surgery Coding Alert

Your practice can have a say during the comment period

A recent memo issued by CMS could spell wider acceptance of bariatric procedures--and that may translate into better coverage for Medicare beneficiaries and greater reimbursement opportunities for your general surgery practice.

On Nov. 23, 2005, CMS announced a proposal to offer national coverage for Medicare beneficiaries under age 65 for open and laparoscopic Roux-en-Y gastric bypass (43846-43888), and laparoscopic adjustable gastric banding (43770-43774). CMS will not cover other gastric procedures, including open and laparoscopic vertical banded gastroplasty and open adjustable gastric banding.

-This proposed limited coverage for bariatric surgery is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives for its beneficiaries, using the best and latest evidence,- said CMS Administrator Mark B. McClellan, MD, PhD.

Coverage Is a Win/Win

Of course, CMS may also view coverage as a long-term cost-cutting measure. -Medicare is on the right track with approving [bariatric] procedures, as they ward off more expensive treatments for diseases [such as diabetes, hypertension and others] that often accompany obesity,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CEO of Coding & Reimbursement Network Inc., which provides medical billing, coding and compliance courses, CEU tele/webinars, products, consulting services and free networking.

Expect non-coverage for older patients: Due to increased patient risk, CMS is proposing the non-coverage of bariatric procedures for seniors 65 years of age and older. Not everyone agrees with the CMS decision to deny coverage for older patients: -It's a big mistake,- says Mary Lou Walen, coding expert at the American Bariatric Surgery Association. Older patients can have more quality of life, including longer lives, and cost the system less money if they undergo bariatric surgery, Walen says.

Expect Limits

Of course, CMS will apply strict rules for when it will pay for bariatric surgery. All patients would have to meet -certain clinical circumstances- for coverage (including the age restrictions noted above), and the surgery would need to occur -in a facility meeting evidence-based standards for bariatric surgery,- according to the CMS memo.

CMS is also proposing criteria for facilities performing bariatric surgery, including credentialing for surgeons and staff and consultant qualifications. And the agency is seeking comment on whether to impose specific volume criteria for facilities or surgeons.

Make Your Opinion Count

CMS- decision is not final, and it invites opinions regarding the proposed coverage. -We are seeking public comment on the best way to provide coverage for this surgery, to reduce the complications of obesity while limiting the risks of the surgical treatments,- McClellan said.

The place to go: You can read the entire text of the Medicare memo on CMS- Coverage Web site at www.cms.hhs.gov/coverage.

CMS will issue its final decision -after careful consideration of the public comments,- so now is your chance to make your voice heard. Your practice can submit its comments directly to the coverage Web site.

Get the coding scoop: For complete information on how to apply gastric banding codes 43770-43774, see -The Laparoscopic Banding Code You-ve Waited for Is Here,- General Surgery Coding Alert, January 2006, page 1.