Medicare Compliance & Reimbursement

Only certified facilities will meet coverage criteria.

Your surgeon can obtain Medicare reimbursement for the fast-growing area of bariatric surgery--but only if you master the coverage criteria.

The Centers for Medicare & Medicaid Services will cover some, but not all, bariatric procedures, according to Transmittal 54, dated April 28.

Covered procedures include:

• open and laparoscopic roux-en-y;

• laparoscopic adjustable gastric banding; and

• open and laparoscopic biliopancreatic diversion with duodenal switch.

Non-covered procedures include:

• open or laparoscopic vertical banded gastroplasty;

• open or laparoscopic sleeve gastrectomy; and

• open adjustable gastric banding.

Requirements: Medicare will only cover the above selected bariatric procedures if patients meet strict criteria. Patients must have a body-mass index of 35 or higher. They also must have at least one co-morbidity related to obesity, and must have failed a previous treatment for obesity.

These criteria are actually less restrictive than the 1991 National Institutes of Health criteria, which providers have been following for the past 15 years, according to Mary Lou Walen, coding expert with the American Society of Bariatric Surgery. The NIH guidelines call for two co-morbidities instead of one.

After a lengthy process, during which Medicare almost denied coverage for bariatric procedures altogether, it's interesting that the program ended up with requirements that are less stringent than the national ones, Walen notes.

Surgery is only covered in a facility certified by the American College of Surgeons as a Level 1 facility, or certified as a Bariatric Center of Excellence by the ASBS.

This requirement is trickier, says Walen, because the ASBS and the ACS didn't have much warning that facilities needed to be certified. Now some facilities that were working towards "center of excellence" status will risk having interruptions in patients' access to care while they complete the process.