General Surgery Coding Alert

Questions: Recently, the surgeon performed a gastroenterostomy (gastric bypass) with 140-cm limb. I submitted 43846, but the payer rejected the procedure as "experimental." Any suggestions?


New Jersey Subscriber

Answer: You should appeal the payer's decision. More than likely, the payer is using the now-outdated definition of 43846 (Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy).

Prior to 2005, this code specified a short limb of 100 cm or less (rather than 150 cm or less). Payers seeing a limb of more than 100 cm were prone to deny the claims. With the revision of the definition of 43846 in 2005, however, payers should recognize all claims for gastric bypass with limbs of up to 150 cm as legitimate.

In your appeal, cite the updated definition of 43846 with a copy of the relevant pages from your CPT manual as proof of the code change.