Wiki 43775 performed for a NON-Bariatric DX

[khkoch]

We had an elderly patient 93 y.o. diagnosised with stomach cancer, who was sent to our office for a consultation for general surgery. Our surgeon is certified in general surgery & bariatrics and performs the majority of his surgeries via robot. He reviewed the patient chart and scheduled him for a robotic sleeve gastrectomy, 43775, this has LCD's in place for Bariatrics. The surgery was necessary and the patient did well after surgery with no complications. We looked for other CPT codes that were not listed under bariatrics, but he specifically did the sleeve gastrectomy. The claim was originally denied by Medicare, which we expected, we filed an appeal sending in all documentation, op report, and pathology report. Medicare denied the appeal.

Does anyone have any other suggestions to get this approved, besides just writing off the surgery? I have looked for other documentation, but surely they must know that this procedure can be performed for other reasons than just weight loss.

 

[cgaston]

Since this code is listed under the "Bariatric Surgery" heading it should be used for bariatric cases only.


My suggestion would be to use 43659 unlisted laparoscopy procedure on the stomach, compare it to 43631 (open partial gastrectomy) and explain the difference is this was performed laparoscopically instead of open and attach the report.