General Surgery Coding Alert

Presented by Jan Rasmssen, CPC, ACS-GI, ACS-OB

Bariatric surgery, gastric restrictive procedures, bypass procedures are performed to control the amount of food intake and/or nutrient absorption to promote weight loss in the morbidly obese.  When you get started one of the first things that you need to do is pre-certification.  Part of that is understanding the definition of overweight versus obesity. 

Overweight or obesity is determined by the BMI--body mass index--which is a ratio-based calculation of weight and height.  Obviously, the higher the body mass indeed, the greater the risk of lung diseases, high blood pressure, coronary artery disease, stroke, osteoarthritis, cancer, and type II diabetes.  Morbidly obese people have trouble with their joints and their lower extremities--hip, pelvis, knees and that type of things.  So obesity is an increased risk for additional problems. 

-Overweight- signifies an excess body weight when compared to established standards.  The next issue is who establishes the standards?  There are a lot of people who would like to establish standards.  Those standards have changed throughout the years.  It really is a terminology that is somewhat negotiable.  The overweight person him or herself is not an obese person.  BMI range for overweight individuals is typically 25-30 kg weight ratio.  Now this weight can be derived from muscle, bone, fat, body water and that type of things and one example from some of my resources is where they are saying a bodybuilder or a professional athlete may be technically considered overweight due to increased muscle mass, but that does not mean that they are obese. 

Obesity refers specifically to excess body weight that stands from an abnormally high percentage of body fat.  The bone structure and muscle mass would not play a role in determining obesity.  There has been a long debate about the cut-off for obesity through the years.  The American Hospital Association defines obesity as -body weight 30% greater than the ideal body weight.-  You can find probably 3-4 different charts for ideal body weight and they vary by 5-6 pounds, but not very much.  Others consider the threshold to be 25% body fat for men and 35% body fat for women, however, there is an agreed upon range that is usually agreed upon by most Federal agencies and medical societies, and that is the body mass of 30 kg or greater.  So that is the body mass index that is most generally agreed upon.

Morbid obesity is the basis for gastric restrictive bypass or bariatric surgery.  By the way, we do have a specific code for morbid obesity and that is 278.01.  278.00 is obesity unspecified.  Next year in October we are getting a new code--278.02--for just an overweight person.  So you are going to probably need the morbid obesity to get paid for gastric bypass for bariatric procedures.

Common coverage criteria:  First of all, the patient must meet the obesity guidelines previously stated.  Documentation is necessary for most insurance companies stating that the patient has been unsuccessful at obtaining or achieving sustained weight loss using other methods.  Many insurance companies are going to ask for copies of their previous medical records, list of all medications they have been on, their diet history, receipts for diet programs/exercise programs that they have been unable to sustain weight loss with, and sometimes a letter referring patient to surgical evaluation from primary care.  Basically what they want to know is that they have not been able to lose weight with other treatments and are at high risk for developing health problems.  The bariatric surgery option should be an option of last resort and that is very, very important to understand--the last resort criteria.  The want to make sure that the patient has been unable to achieve weight loss with other circumstances and treatment. 

Candidates for surgeries according to standards by the National Institute of Health.  They have different criteria.  First of all, they have the criteria of at least be 100 pounds over ideal body weight, have a body mass index of over 40 or have a body mass index over 35 along with significant comorbidities--diabetes, sleep apnea, hypertension, cardiovascular disease, and have no significant contraindications for surgery.  That is the standard of care per the National Institute of Health.  This is something that you can use while you are appealing.  You can use these criteria and say, -they meet the National Institute of Health's standards for surgery.-

Other considerations:  They have been obese for at least five years.  One of the articles that I read mentioned that there are people that will try to become more obese just to get the surgery.  They do not want to see that happening.  They want to see that the patient has been obese for at least five years, does not have a history of alcohol abuse, does not have depression or other major psychiatric disorders.  They are between the ages of 18 and 65 and the risk of serious comorbidities and possible accompanying complications must be greater than the potential complications for the procedure.  Not all of these criteria are going to be required by insurance companies, but these are common components of criteria that you will see for coverage. 

Qualifying for surgery:  Most surgeons and insurers also require a psychological evaluation to assess: First, whether the prospective patient has a clear understanding of the risks and benefits of the surgery.  They need to be clearly informed that there are complications and that there is a fairly high death rate for some of the procedures.  They need to be able to outweigh or be able to weight those considerations against their current medical history.  Also, they want to evaluate whether the patient has a realistic assessment of personal outcome.  Just because the patient is able to lose weight having had bariatric surgery does not mean that it is going to solve all the problems in that patient's life and they want to make sure that that patient understands that.  Quite often excessive weight loss can cause problems within a marriage and they want to make sure that that patient and the spouse are able to deal with the changes in the patient's psychological makeup and appearance. 

The motivation and discipline they want to make sure is there to follow through.  Just because a patient has surgery does not mean that they do not have to change their dietary habits, change their outlook on foods.  The patients come to the table with a lot of psychological issues and they want to make sure that the patient is motivated and is able to follow the discipline post-surgery to have successful sustained weight loss. 

Three key steps to reimbursement:  The surgeon's office needs to submit an application requesting pre-authorization submitting the information that we previously discussed supporting the medial necessity as required by the insurer.  Now this means that the patient or the surgical office is going to have to determine what the insurer's guidelines are.  That letter should have two distinct goals: A) you must have the insurer determine medical necessity for the procedure that the patient meets the insurer's criteria for medical necessity; and B) have the insurer give approval for the procedure. Just because the insurer agrees that the procedure is medically necessary does not mean that the procedure is approved for payment.  The patient's policy may simply not cover or specifically exclude the procedure itself so identifying the medical necessity alone is not enough.  You must have approval.  If the initial application is denied, appeal, appeal and appeal.  But you cannot appeal if the procedure is specifically excluded.  There are insurance contracts that will specifically exclude bariatric surgery or coverage for any obesity.  Some insurers will automatically deny on initial application and then you have to go through the appeal process to obtain approval for the procedure itself. 

Coverage issues:  Hospitals and physician services to treat obesity are excluded unless the treatment is for certain co-existing conditions and sometimes it is covered on a case by case basis for Medicare.  We all know that in July 2004, Medicare recognized obesity as a disease.  While it opens the door for possible treatment of obesity, it really does not change the current coverage determination.  Treatments for obesity alone are still not covered and they are only covered under certain criteria.  That criteria is on slide #15 of your handout.  Basically Medicare Coverage Manual defines obesity and the justification for treatment as justification when there is medical conditions associated with the obesity.  Such as: hypothyroidism, Cushing's disease, hypothalamic lesions or aggravation of cardiac/respiratory diseases, diabetes and hypertension.  Services in connection with the treatment of obesity are covered when these services are interval and the necessary part of treatment for the above, or the Cushing-s, hypothyroidism, etc, related medical condition.  Again, obesity alone is not a covered diagnosis.

On slide #16, you will see the coverage from the Medicare Coverage Online Manual 100.1 where it says -gastric bypass surgery for extreme obesity is covered if 1) it is medically appropriate for the individual and the surgery 2) is to correct an illness, which caused the obesity or was aggravated by the obesity.  So they are looking at comorbidities--what else is going on.  Now when you look online at the Medicare Individual Payers, LMRPs and LCDs, Empire has a very specific policy.  It is a good policy to review even though you are not in an Empire criteria area.  Georgia has a policy to currently review the mini gastric bypass procedures on a case-by-case basis and they want that listed with an unlisted code.  It requires a copy of the operative note, peer review and medical literature supporting the procedure, and is now considered a standard of care.  Those are the only two states that I could find a specific policy that was related to that state in itself that was not based on the national policy in the Online Manual, which as I stated, is pretty clear and is on slide #16.

Now Federal Medicaid law does not mention coverage of gastric bypass specifically, however, the components of the surgery, the inpatient, hospital and physician services are required services for coverage under Medicaid Policy.  Some administrative tribunals and individual states have ordered state Medicaid programs to cover gastric bypass surgery as medically necessary on an individual claimant basis; in other words, the individual appeals and the administrative tribunal in that state said that the Medicaid carrier/payer had to cover the procedure. 

There is a Web site that I have given you in your handout that shows Medicaid coverage data as of September 2004.  Basically that data states that it is covered in all states except Washington DC, Delaware, Montana, Ohio, South Dakota, Texas and Vermont.  Now policies may limit the type of surgery coverage.  They do not cover all bariatric procedures.  You need to look at your individual state policy. 

Private insurance is a whole different animal in and of itself.  According to the AMA, the number of gastric bypass surgeries has climbed more than 500% from 1993 to 2003.  In 1993, there were approximately 16,800 gastric restrictive or gastric bypass surgeries performed.  In 2003, it has climbed to 103,000.  Coverage is going to vary by payer and policy.  Some payers are currently recognizing some types of bypass surgeries, but not all procedures.  The two most commonly recognized are the LAP BAND procedure and the Roux-en-Y procedure.  Some payers that previously allowed coverage for some bypass procedures are now eliminating coverage.  Specifically, Blue Cross Blue Shield of Florida, Nebraska and Alabama have eliminated coverage for gastric bypass and obesity payments.  CIGNA is eliminating coverage in some states.  Their rationale is that they cannot afford to keep paying for risky procedures with high complication rates and death rates.  For example, the estimated death rate is 3/1000 according to the AMA and MedNews.  They are very high-cost procedures.  The high rate of complications is a consideration.  Right now, the estimated complications is 1/5.  I happen to know three people personally and two of the three are having complications from bypass procedures.  There is also a high rate of noncompliance.  People find out that once they have done this--they have had the procedure--down the road in 3-5 years, they get a little bit loose with their dietary habits and they start gaining the weight back.  Also a concern is that bariatric surgeries are being increasingly done by less qualified doctors.  Bariatric surgery is not a specialty certified by the board of surgeons so the level of training required for surgeons varies widely.  There has been an influx of surgeons into the bariatric field.  In 1993, there were only 168 surgeons that focused on bariatric or performed bariatric procedures.  In 2003, there are 103,200 surgeons that perform bariatric procedures.

Some carriers/payers are looking at Centers of Excellence with restrictions for future coverage of bariatric procedures.  In other words, they are going to set up Centers of Excellence where they know that the surgeons performing the procedure have exceptional background and training, that they have low rates of complications and that type of thing.  There are also some state legislators that are considering mandatory coverage.  Connecticut has a bill currently out there where they are considering mandatory coverage.  Georgia and Louisiana are considering looking at mandatory coverage policy.  Again, any of these policies are subject to change and they are changing probably as we speak.  We went on the internet again today.  I did this research maybe five weeks ago.  You may see some changes.

On slide #20 is a list of payers and procedures themselves that many payers do not cover at all.  Jejunoileal bypass, biliopancreatic, BPD--biliopancreatic with duodenal switch, long-limb gastric bypass, long Roux-en-Y greater than 150 cm, horizontal gastric partitioning/gastroplasty, gastric wrapping, gastric bypass using Billroth type anastomosis or the mini-gastric bypass procedure, Garren-Edwards gastric bubble, Gastric Electric Stimulation for the treatment of obesity (gastric pacemaker), and they are not covering these for multiple different reasons.  Some because of the high risk of complications.  Some because they are not proven techniques. 

On slide #21, you will see a partial list of companies that are known to either partially or completely cover the LAP BAND system surgery.  Blue Cross in some states, Humana, First Health, One Health, you can read this.  Again, this list should not be construed as a guarantee that it will be covered, but it is provided for informational purposes only.  I cannot stress enough that for each insurance company that you are dealing with you need to know what their policies are.  Blue Cross Blue Shield can change by the payer themselves.  Some private companies can say that they choose to absolutely restrict coverage for gastric bypass or bariatric procedures. 

On page #22 or slide #22, there is a Web site for updated information regarding bariatric surgery by state payers.  It actually has a map on that website.  You can click on that map and gather information from patient's that have had the procedures and that type of thing.  Also there is a Web site there for a sample appeal letter. Now this one happens to be an appeal letter for Roux-en-Y, but it will help you construct appeals and give you a base to start with for constructing appeals.  Some data that you can use to construct your appeals and use in your appeals is that obesity is now a major epidemic and it is going to get worse if it goes unchecked.  The cost of obesity-related illnesses reached $75 billion in 2003 and is expected to climb over a $110 billion in 2004-05.  Obesity has now gained on smoking as the top cause of death in the United States.  Those are some things that you want to bring in your appeals, but in some cases if the insurance clearly does not cover gastric bypass it is going to be the patient responsibility and you may have nothing to work with.

Also, there is a sample policy and it is probably the best policy that I have even seen on a gastric bypass or bariatric procedures and it is put up by Regence.  That insurance is a Blue Cross Blue Shield policy for Idaho, Oregon, Utah and Washington.  It is a very, very, very detailed policy outlining scientific data to support the coverage and non-coverage of certain procedures.  It is well worth your time to look up that Web site that you have been given in your handouts to help you understand the criteria behind it and the thought process behind it. 

Now we are going to quickly go over some GI anatomy because understanding the anatomy will help you when you are looking at operative reports to determine the actual procedure that was performed.  Basically the GI system starts at the mouth and goes all the way down to the anus.  The primary purpose of the digestive system is process food into nutrients to feed the body.  The primary elements of the digestive system are the mouth, pharynx, esophagus, stomach, small intestine or small bowel, and the large intestine or large bowel.  There are three additional organs that contribute to the digestive process and they are the liver, the gallbladder and the pancreas.  The stomach is basically the holding and processing center for the digestive system.  Once the food is digested, it is passed into the small intestine.  There are two sphincters you need to be aware of.  The most important one is the pyloric sphincter.  This allows food to exit the stomach and into the small intestine when it has been sufficiently digested.  Some bariatric procedures are pyloric sphincter sparing procedures where the pyloric sphincter remains intact and other procedures remove the pyloric sphincter.  You need to be aware of which procedure does what.  That way you can identify the issues.

Slide #26 has basically an illustration of the stomach.  The important part is that you understand the cardia, the greater curvature, the lesser curvature, the antrum and that pyloric sphincter.  Different procedures will remove different parts of the stomach and will remove or keep the pyloric sphincter.  The small intestine connects the stomach and the large intestine.  The duodenum is one of the important parts because that is where the liver, gallbladder and pancreas empty bile and fluid to hep process the food.  The majority of iron and calcium is absorbed in the duodenum.  The liver, gallbladder and pancreas all enter into the duodenum and they have the biles and fluids, which break down and help digest or help absorb the nutrients into the small intestine.  The jejunum is the second part of the small intestine, it is about 8 feet in length.  The ileum is the third part of the duodenum about 11 feet in length and it attaches the large intestine to the cecum.  Food is digested in the small intestine and absorbed in the small intestine. It is dissolved by the juices from the pancreas, liver and intestine.  Most of the calories that a patient gets in a day are absorbed in the small intestine.  Then we have the common bile duct, the pancreatic duct, the papilla of Vater.  These are all terms that you are going to see in the description of the procedure.  Bile is made by the liver and starts to aid in the digestion of the fats.  It helps to emulsify fat globules so that they present a larger surface for digestive enzymes that break them down.  The gallbladder acts as the bile reservoir and during the digestive process the gallbladder contracts and secretes bile in order for the small intestine to digest fat.  The important part of this is that you know that these bile ducts enter into the duodenum.  So if a patient is having a bypass procedure, they are eliminating or bypassing part of the small intestine to eliminate or restrict absorption of these nutrients, fats and that type of things.

The pancreatic duct connects the duodenum for the transportation of pancreatic juices and you all know that diabetes is related to the Pancreas.  There are certain juices that come from the pancreas that are going to be absorbed and help break down the foods and that type of things.  They are related to diabetes.  Papilla of Vater is also known as the hepatopancreatic ampulla and it is the dilation formed by the juncture of the pancreatic bile duct as they open into the duodenum.  Some of your surgeries will indicate -above and below the ampulla of Vater.-  The large intestine is actually the dumping ground.  Unabsorbed digestive food is eliminated through the large intestine.  The large intestine has very little to do with the absorption of nutrients and fat calories.  On slide #30 is the breakdown of the large intestine, which is not nearly as important as our understanding of the small intestine. 

We have gastric restrictive concepts.  How are these procedures performed and what is it that they do?  There are many different techniques and there are three in particular.  -Restrictive only- means that it restricts the food consumption--they are cutting down the size of the stomach and it may or may not be as successful as gastric malabsorption where it is restrictive only, because if you are only making the pouch for the stomach smaller it is easy to cheat and over-stretch that stomach pouch and eventually get it up to a larger size.  Malabsorption is where they exclude most of the small intestine from the digestive tract and that limits the absorption of the nutrients or calories.  Now strictly -malabsorption procedures are not currently recommended because o the high risk of severe nutritional deficiency postoperatively.  If you are not getting your nutrition, your calcium, your nutritional food to feed your body and you are not getting the nutrients that you need there obviously is a risk of deficiency and that type of thing.  Osteoporosis and that type of complication.  Then there are the -combined restrictives- where they do the restrictive with malabsorptives.  Your gastric bypass surgery is a combined.  They make the stomach pouch smaller and they also have a malabsorptive component to it. 

Let us move on to the coding for the restrictive only procedures.  Codes that describe open restrictive only techniques.  We have two codes: 43842 and 43843.  43842 is gastric restrictive without gastric bypass for morbid obesity, vertical band and gastroplasty.  43843 is other than vertical banded gastroplasty.  Again, these are making the stomach pouch smaller, but they do not have a malabsorptive component.  Vertical banded gastroplasty involves partitioning of the stomach into a smaller upper gastric pouch that connects to the lower stomach portion through a smaller stoma or opening.  It uses both the band and staples to create a small stomach pouch.  It restricts the food consumption, but maintains the anatomic gastric continuity.  In other words, the distal stomach is still there.  The pyloric sphincter is still there and the food still goes through the duodenum, jejunum and ileum.  This is not currently used very often.  We have better and more appropriate procedures, less extensive procedures nowadays.  There is a picture of this particular procedure--the vertical banded gastroplasty--on slide #34.  You can notice that there are staple lines and there is a band.  It looks to me almost like a jelly donut.
 
Then we have the adjustable banded gastroplasty--ABG--and that is reported with 43843.  This is the open adjustable banded gastroplasty.  Basically what they do is a hollow band made of silicon rubber is placed around the stomach near the upper end and it creates a very small pouch.  Then they narrow the passage into the rest of the stomach.  This band can be inflated with a salt solution through a tube that connects to the band to an access port placed under the skin.  The access port is placed in the lower abdomen.  It could be tightened or loosened as necessary.  Right now, there is no CPT code for the saline injections to fill the balloon.  Most places are coding it as an E&M and a lot of places are considering that patient responsibility.  Many payers will not pay for those encounters to fill that balloon.  There is an S-code that may be used by Blue Cross Blue Shield and that S-code is the S2083--adjustment of gastric band diameter by a subcutaneous port by injection or aspiration of saline.  If they are going to allow you to use that code then you are going to have to put a 58-modifier on there--planned--because it is planned that you are going to adjust that gastric band.  There is no absorptive component to this procedure and the band may be removed, if necessary.  In a way, it is less risky.  Again, any time that you do a procedure in the abdomen or in the stomach area, there is a risk of adhesions and that type of thing. 

Right now there is no CPT code for the laparoscopic banded gastroplasty and this is the most common performed procedure.  Not all insurance companies cover it, but you will have to use the unlisted at this time accept for Blue Cross Blue Shield, which has an S-code for that also and that is S2082--laparoscopy, surgical gastric restrictive procedure adjustable gastric band--and it includes the placement of the subcutaneous port.

The next slide--slide #36--shows you a picture of a gastric band and a port.  To me it is very, very similar to your vascular access procedures, but at the end instead of having a needle they have a band that goes around the stomach. 

Slide #37 shows the results of that with the band around the stomach.  They have really made that upper portion where the patient can initially put the food in very, very small. 

43843: Not only doe it include the adjustable band procedure, it also includes other gastric reservoir reduction procedures, such as stomach stapling, gastric wrapping; and these are really pretty much out of being done, and they are out of performance right now.  They are not in favor right now.  The gastric banding is probably the most common one, but just to let you know that gastric wrapping is taking the stomach and it is encased in mesh, and it helps maintain the restrictive size of the reservoir without gastric bypass.  But again it is not able to be adjusted as the patient progresses.

Some terms that you are going to see associated with gastric banding are on page #39.  I am not going to read them to you.  Just so that you are aware of the terminology that you might see associated with gastric banding.  I wanted to make sure that you had those terms. 

On slide #40, we are talking about restrictive with malabsorption component.  Those are three codes for open procedures:  43845, which is basically your biliopancreatic diversion with duodenal switch.  We are going to talk about what that means in a minute, but it is the pylorus preserving duodenal ileostomy and ileostomy 500-100 cm of a common channel.  We will tell you what that means in a minute.  43846 is your Roux-en-Y and 43847 is gastric restrictive with small bowel reconstruction to limit absorption, better known as BPD--biliopancreatic diversion without duodenal switch. 

Let us talk about 43846 because this is the one that is most often accepted as a payable procedure by insurance companies outside of the LAP BAND procedure.  What they do is that they create a small pouch in the antrum or the upper part of the stomach to restrict the food intake and then they create a Y-shaped section of small intestine.  That is attached to the pouch to allow food to bypass the lower portion of the stomach and the duodenum and the first portion of the jejunum, basically, the second segment of the small intestine.  So it bypasses all of that.  So now you have a small ability for intake of food and you are also bypassing some of the absorptive area where the calories are absorbed.  Quite often they will do a cholecystectomy with a Roux-en-Y because there can be gallstones that develop from rapid weight loss.  If the cholecystectomy is prophylactic, it is not going to get paid separately.  If they have indications, including cholelithiasis and cholecystitis at the time that you do the gastric restrictive or gastric bypass procedure and it is documented as having existed at the time of the procedure, you may get paid separately for the cholecystectomy.  Basically what they are doing is the smaller stomach is connected directly to the middle portion of the small intestine to jejunum so keep that in mind as the definition of the Roux-en-Y.
 
The procedure routes the food around the distal portion of the stomach to the pyloric sphincter.  The valve is no longer working and because that pyloric valve is bypassed, one of the common problems that we have is large amounts of food, and carbohydrates especially, may enter that small intestine in bulk because they do not have that valve that controls the movement of the food any longer.  This can cause rapid distention in that jejunal loop, which is attached to the stomach.  This complication is known as dumping syndrome.  The dumping syndrome can cause severe bloating, nausea and that type of thing.  Another side effect of this procedure can be ulcers in the small intestine due to stomach acids.  These stomach acids are normally absorbed before reaching the small intestine so there are some complications associated with that. 

In 2005, the Roux-en-Y was revised from short limb of 100 cm to 150 cm.  This is the standard right now.  It is more effective for patients with greater obesity--225% of ideal body weight.  Basically it increases the weight loss because more of the small intestine is bypassed. 

The next slide, which is slide #44, gives you an idea of the process and the size of the stomach.  This is more for informational purposes so that you can understand the procedure itself.  They are talking about the stomach being made small enough that they cannot stretch it too far later because eventually it will stretch a little bit.  They are basically taking that stomach down about the size of a golf ball.  At the end, it tells you the digestive juices from the stomach, liver and pancreas travel down that bypassed duodenum and jejunum and they are added to the food that has come down that Roux limb at the very, very almost end of the small intestine; so there is less room and less area for that food to be absorbed and that is how it works.  There is a picture of the Roux-en-Y in your next slide which shows how it is connected up.

BPD--biliopancreatic diversion--could be performed alone or with a duodenal switch.  One of the terms that you may see is BPD-DS or DS or BPD.  Another terminology is Scopinaro procedure.  These are malabsorptive operations that causes the food to be poorly digested and absorbed.  A larger stomach portion is made.  They leave a larger stomach pouch by removing about 2/3 of the stomach, but instead of the size of a golf-ball it is the size of a can of soda.  The remaining stomach is reconnected to the ileum.  They are bypassing much more of the small intestine.  Almost 9 feet of that small intestine is bypassed.  All the enzymes and bile from the liver and pancreas meet digested food further down in the ileum at about 500-100 cm from the large colon.  Again there is less room for absorption of calories and that means that you are going to have a greater weight loss. 

The BPD with diversion:  The main difference between BPD and the BPD with diversion is which part of the stomach is removed--and this is why it is quite important to understand the terminology.  BPD alone has the lower part of the stomach removed, and BPD with duodenal switch has the left side of the stomach or the lesser curvature removed.  The second determining difference is the presence or absence of the pylorus or pylori sphincter.  The DS duodenal switch maintains the presence of the pylorus, but the advantages of that remain unclear at this time according to scientific studies. 

On slide #49, you will see a picture of the different procedures: The BPD without the duodenal switch and the BPD with the duodenal switch.  You can see the different part of the stomach that has been removed in those illustrations.  43845 is your BPD with duodenal switch and that would be the code that you would use for that.  Slide on Page #50 describes how this is performed and I do not need to go over that again.  43847 is your BPD alone without the duodenal switch.  There is an additional step of the small intestine reconstruction--it is reconstructed a little bit differently than the Roux-en-Y.  This is known as the Scopinaro procedure.  These all have high risks of nutritional deficiencies and are most often not covered by insurance.  We have two new codes in 2005 and it is about time for laparoscopic gastric bypass procedure.  43644 is your laparoscopic Roux-en-Y, the equivalent open code is 43846; and, then we have your 43645, which is your laparoscopic BPD, the equivalent code for that is 43847.  As I said previously we did not have a laparoscopic code for the laparoscopic adjustable band.  At this time, I would suspect that it would not be long until we have that.  Right now what we have to do is that we really have to recommend the unlisted code if you are doing a laparoscopic adjustable band.  Now if an insurance company tells you to bill the open adjustable band in place of the laparoscopic then I would suggest that you get that in writing from them.  That way you cannot be accused of misrepresenting the procedure that was performed. 

A little bit on the mini-gastric bypass.  There is no current CPT code for a mini-gastric bypass.  You would have to use the unlisted code, 43659.  This is a variant of the gastric bypass.  If you are using a laparoscopic approach, the stomach is segmented and it is very similar to a Billroth II.  Instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach.  This is the unique aspect of the procedure--not based on the laparoscopic approach itself, but rather on the type of the anastomosis used.  I remember earlier in the discussion, I did specifically say that there is one payer--it eludes me right now--that is looking at the mini-gastric bypass as a payable procedure, but it is on a per-patient basis.  CPT 43846 really does not accurately describe the mini-gastric bypass since the CPT is specifically for the Roux-en-Y so you would have to use the unlisted code.  Well, we have got done about 10 minutes early so I will now open the lines for questions. 

Thank you Ms. Rasmussen.  Ladies and Gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press the star (*) one (1) on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press pound (#).  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question, you may reenter the queue by pressing star (*) one (1). 

Our first question comes from Nicole Bartley of The Coding Institute.  Please state your question.

Question (NB):  Hi Jan.  I do have this one question that was sent in prior to the teleconference.  It asks could you please stress how to get paid for hernia repairs in connection with gastric bypass?

Answer:  Hernia repairs in conjunction with any other abdominal procedure is going to require that the documentation indicates that the hernia was in an area other than where the opening for the other procedure is being performed.  In other words, if you are doing an open procedure and in the course of closing that abdomen from that open procedure you also repair a hernia, you will never get paid for that separately.  If it is a laparoscopic procedure, by closing the port area, you also incorporate the hernia repair in that, most likely it will not get paid either.  If the hernia repair, because there is a hernia there in the closure area, takes significant additional work time I would recommend using modifier-22.  If you are truly in a separate area--the hernia is in a separate area other than the opening or the laparoscopic opening--then you would have to report the hernia with modifier-59.

Comment (NB):  Thank you very much.

Our next question comes from Debbie Mediavilla.  Please state your question.

Question (DM):  I have a slight problem--I have a couple of slides where you are stating there are Web sites like on slide #22--Web sites for updated information regarding bariatric surgery by state payers.  That did not print out. 

Answer:  Did not print out?  Was it too light maybe?

Question (DM):  I think so.

Answer:  Okay, the state payers--and this is a great site--was www.obesityhealth.com/morbidobesity/insurers.phtml.  It actually has a map and you could click on your state.  It has coverage information from that state itself.

Question (DM):  Great.  Thank you.

Answer:  Right and the appeal letter address - www.obesityhealth.com/morbidobesity/m-instrouble.phtml.

Question (DM):  Fantastic.  That will help tremendously.

Answer:  Right and also on - did you get the Web site for regence?

Question (DM):  Yes that printed out.  No problems with that.

Answer:  Okay.  Well I think it is because when we put it into the slides it printed as an immediate access in the light-blue so if you get a chance to read that regence policy, it is an incredibly educational policy on the thought process behind covering procedures and how the procedures are performed.

Comment (DM):  I will definitely look both of these Web sites up.  Thank you.

Our next question from Andrea Breinholt of Cornell University.  Please state your question.

Question (AB):  My question is on page #13 of the presentation--slide #25.  You mentioned that with the pyloric sphincter some of the procedures that are done keep it intact and some do not and we are supposed to be conscious of which do and do not, but does this impact reimbursement?

Answer:  No it does not impact reimbursement, but when you are going through the operative report and you are trying to determine what procedure they actually did, by the description that I gave you of the individual procedures you will have a better idea.  If the pyloric sphincter is intact you will know that it is not the BPD.  Using the illustrations will help.  Most insurance companies are not paying the BPD, the BPD with duodenal switch and that type of thing.  What I found in the research was that the most commonly covered are the laparoscopic adjustable bands and the Roux-en-Y.  The rest of them are considered them at too high risk because of the complications of nutritional deficiencies and that kind of stuff and the other complications associated with dumping syndrome and things like that.  If the pyloric sphincter is gone you are going to have a lot of problems or the risk of complications from the dumping syndrome and that type of thing are very, very high.  What so many insurance companies are saying is that they are going to stop paying for bariatric procedures at all are saying that the cost of the procedure alone is expensive and the cost of complications have upped that expense tremendously and they just feel that they cannot cover them any longer.
 
Question (AB):  Also on page #18 and slide #35, you said that the LAP BAND is typically not paid so the offices either bill the patient or something else.  What was the something else?

Answer:  They either have to try to appeal or - the #18 is addressed specifically to Medicaid and what I put in there was that even though your Medicaid at this time is not covering it, if you can appeal based on the patient's comorbidities, some of the administrative tribunals have then been ordering them that they must pay based on an individual-patient basis, based on that patient criteria. 

Question (AB):  Okay.

Answer:  Otherwise it would be the patient's responsibility.  What I was seeing was that the cost of different procedures runs anywhere from $20,000-$35,000.  Does that answer your question?

Comment (AB):  Yes it does, thank you.

At this time, we have no further questions.  I would like to turn it back to Ms. Rasmussen for any closing comments.

I want you all to know that if you go on the internet--and I did a lot of research on this, if you go on the internet--and look for your policies.  If you look under bariatric surgery reimbursement or gastric bypass reimbursement, you will find a wealth of information out there.  Obviously, the Web sites that I have given you have lots and lots of information there.  Your bariatric society has information.  That is absolutely the best thing that you could do when you are looking at coverage.  It is, though, the patient's responsibility to know their coverage and there are some insurance companies and insurance policies themselves that restrict the coverage completely so you need to be aware that you need to make your patients aware of that also.  Appeal, appeal and appeal.  If they have comorbidities that you can support that truly, truly need to be addressed and the patient has failed other dieting or weight loss programs, make those patients aware that they need to have reports, receipts and that types of things to help support their failure and past failures on other weight loss methods.  If we can be of any further help or if you think of any questions later in the week - sometimes, I do that - when I get away from the program I say, -Ah! I should have asked about that.-  You can e-mail your questions to Nicole at Medville.com and she will make sure those questions get to me.  If I personally cannot answer them I usually have enough resources that I can get them to answer for you so feel free to send any additional questions to Nicole.  Thank you for attending.  We appreciate it.

This is the conclusion of " 7 Field-Tested Secrets for Securing Gastric Bypass Pay-up" national teleconference.  We hope that you enjoyed this session.  Please complete your teleconference evaluation form and return it to The Coding Institute at the address listed on the form.  Ms. Rasmussen, The Coding Institute and I would like to thank you for attendance.  To end this call, simply hang up your phone.  Goodbye.

To view the slides please refer to this issues slides.