General Surgery Coding Alert

Question: We’re getting denials for bariatric surgery even though the surgeon documents the patient’s BMI as showing morbid obesity. What are we missing?

Texas Subscriber

Answer: You are correct that to show medical necessity for bariatric surgery, you must document morbid obesity. However, many payers also require that you demonstrate a comorbidity to justify the surgery. You should become familiar with each payer’s policy on bariatric surgery to ensure coverage for these procedures.

For example, you should list E66.01 (Morbid [severe] obesity due to excess calories) and document the patient’s body mass index (BMI) with the appropriate code such as Z68.45 (Body mass index [BMI] 70 or greater, adult).

That’s not all: For many payers, you must also identify the additional issue your patient has which prompts the procedure. For example, if the patient has Type 2 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 also 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.

For instance: CMS states, “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.”