General Surgery Coding Alert

Benefits are more generous than expected

Beginning immediately, you-ll be able to offer a greater variety of bariatric surgery options for Medicare beneficiaries. CMS outlines which procedures -- and which patients -- will qualify for coverage.

Get the Skinny

On Feb. 21, Medicare issued a press release stating that it would now cover Roux-en-Y gastric bypass (43846-43847), laparoscopic adjustable gastric banding (43770-43774), and biliopancreatic diversion with duodenal switch (43845) for eligible Medicare patients. All other bariatric procedures will remain noncovered, at least -until other evidence is available,- according to the CMS release.

-Bariatric surgery is not the first option for obesity treatment, but when performed by expert surgeons it is an important option for some of our beneficiaries,- says CMS Administrator Mark B. McClellan, MD, PhD. -While we want to see more evidence on the benefits and risks of this procedure, some centers have demonstrated high success rates, and we want to ensure access to the most up-to-date treatment alternatives for our beneficiaries.-

Medicare promised a final decision memorandum on the topic at www.cms.hhs.gov/center/coverage.asp, but that document was not yet available when this story went to print.

Overweight Alone Won't Ensure Coverage

As McClellan's comments suggest, not every patient will qualify for coverage.

Most substantially, Medicare will not cover bariatric surgery in patients who only have a diagnosis of obesity. Instead, CMS will only provide coverage for patients who present with various comorbidities, including hypertension, type-II diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers.

Specifically, CMS guidelines dictate: -Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one comorbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity.-

Additionally, the agency 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.
 
-Utilizing these groups- expertise will ensure that beneficiaries will receive optimal care in a manner that provides the greatest likelihood of successful outcomes from this important procedure,- said Barry M. Straube, MD, CMS- acting chief medical officer.

See for yourself: You can find a list of qualifying facilities at www.cms.hhs.gov/center/coverage.asp.

Coverage Is Better Than Expected

CMS- coverage decision is more generous than the proposal the agency set forth last November (see -Medicare Set to Expand Bariatric Surgery Coverage- on page 11 of the February 2006 General Surgery Coding Alert). Not only does the coverage decision include biliopancreatic diversion with duodenal switch, but Medicare will also extend coverage for patients older than 65 years of age. The initial proposal didn't include biliopancreatic diversion and specifically restricted coverage to patients younger than 65 years old.

Learn more: 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.

For more information on reporting other gastric procedures described in this article, look to a future edition of General Surgery Coding Alert.