Medicare Compliance & Reimbursement

Carrier loosens red tape on stomach-stapling and bypass operations.

New policies from at least one carrier are going to make life easier for physicians who perform bariatric operations.
 
Compared to older, more restrictive policies, January's local coverage decision from Part B carrier Noridian (L14980) seems fairly easy-going. Noridian will accept just one of a number of secondary diagnoses along with a primary diagnosis of morbid obesity. These include Type II diabetes, hypertension, gastroesophageal reflux, sleep apnea, urinary incontinence, venous stasis ulcer or degenerative joint disease involving the lower back, hips, knees, ankles or feet.

Though Noridian's policy does require documentation of a structured six-month diet, psychological assessment and previous attempts at pharmacologic management, it's still less restrictive than past policies. Some former carrier policies required documentation "that a patient had a life-threatening incipient or actual condition, and they were basically incapacitated from any activities," says Mary Lou Walen, coding expert at the American Bariatric Surgery Association. The patient should have difficulty with walking and other activities of daily living.
    
By contrast, the Noridian policy is "liberal," says Walen.

"We're seeing a lot of insurance companies going that direction, because the results have been so incredibly good for patients," says Marcella Bucknam, HIM coordinator at Clarkson College in Omaha. Patients who weren't able to work have been able to return to work. But this isn't a universal trend, and some insurers are slashing at the procedures.

The other good news is that the American Medical Association's CPT panel appears set to establish new bariatric surgery codes for 2005, according to Walen. Currently, if physicians perform either a banding or a roux-en-y laparoscopically, they must use unlisted procedure code 43659, but open procedures have codes 43842-43848.

But starting in January, physicians will have new codes for laparoscopic approaches, says Walen. ASCS has worked with the American College of Surgeons and the Society of American Gastrointestinal Endoscopic Surgeons to obtain new CPT codes for laparoscopic gastric bypass surgery in 2005.

"That would be wonderful -- way long past due," says Bucknam.