Billing and Coding: Bariatric Surgery Coverage

**Background**  
Coverage of bariatric surgery is described in the Internet Only Manual (IOM)
_Medicare National Coverage Determinations Manual_ , Publication 100-03,
Section 100.1 _Bariatric Surgery for Treatment of Co-morbid Conditions Related
to Morbid Obesity_ and _Medicare Claims Processing Manual_ , Publication
100-04, Chapter 32, Section 150.  
  
The following coding guidance is published based on the requirements in effect
as of the effective date of this article and no longer addresses past
coverage. Prior coverage may be different depending upon the date of service
and can be obtained from the National Coverage Determination 100.1.  
  
As of the effective date of this article revision Medicare (CMS) has
established by NCD 100.1 that the following bariatric surgery procedures are
reasonable and necessary under specified conditions for the treatment of
complications of morbid obesity.  
1\. Roux-en-Y Gastric Bypass (RYGBP)  
2\. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric
Reduction Duodenal Switch (BPD/GRDS)  
3\. Laparoscopic Adjustable Gastric Banding (AGB)  
4\. Laparoscopic Sleeve Gastrectomy  
  
To be eligible for bariatric surgery the patient must have a body-mass index
(BMI)  35, and at least one co-morbidity related to obesity. Further, the
documentation must clearly demonstrate the failure of reasonable non-
invasive/non-surgical treatments for obesity with which the beneficiary has
been compliant.  
  
Noridian considers the following, based on national guidelines for bariatric
care, to be the minimum specifications to be documented in the patient record
in order to demonstrate the beneficiary has been previously unsuccessful with
medical treatment for obesity as required by the NCD:  
  
1\. The beneficiary has been previously unsuccessful with medical treatments
for obesity. The latter includes but is not limited to: active participation
within the last 12 months prior to bariatric surgery in a weight-management
program that is supervised by a physician or other health care professionals
for a minimum of four consecutive months. The weight-management program must
include monthly documentation of patient's weight and BMI, current dietary
regimen and physical activity (e.g. exercise program).  
2\. Physician-supervised programs consisting exclusively of pharmacological
management are not sufficient to meet this requirement.  
3\. A thorough multidisciplinary evaluation is required within the previous
six months which includes **ALL** of the following:  
a. an evaluation by a bariatric surgeon recommending surgical treatment,
including a description of the proposed procedure(s)  
b. a separate medical evaluation from a physician other than a surgeon and
preferably the beneficiary's primary care physician that includes both a
recommendation for bariatric surgery as well as a medical clearance for the
proposed bariatric surgery  
c. mental health and psychosocial clearance for bariatric surgery by a mental
health provider including a statement regarding motivation and ability to
follow post-surgical requirements  
d. a nutritional evaluation by a physician or registered dietician.  
  
 **Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for
Laparoscopic Sleeve Gastrectomy: 0DV64CZ**  
  
 **Nationally Covered Inpatient Facility ICD-10-CM Procedure Codes**  
  
For services on or after October 1, 2014, the following ICD-10 procedure codes
are covered for bariatric surgery:  
  
**Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the
following ICD-10-PCS codes:**

0DB64Z3  
0DV64CZ  
0D16479  
0D1647A  
0D1647B  
0D1647L  
0D164J9  
0D164JA  
0D164JB  
0D164JL  
0D164K9  
0D164KA  
0D164KB  
0D164KL  
0D164Z9  
0D164ZA  
0D164ZB  
0D164ZL  
  
**Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS
codes:**

0D16079  
0D1607A  
0D1607B  
0D1607L  
0D160J9  
0D160JA  
0D160JB  
0D160JL  
0D160K9  
0D160KA  
0D160KB  
0D160KL  
0D160Z9  
0D160ZA  
0D160ZB  
0D160ZL  
0D16879  
0D1687A  
0D1687B  
0D1687L  
0D168J9  
0D168JA  
0D168JB  
0D168JL  
0D168K9  
0D168KA  
0D168KB  
0D168KL  
0D168Z9  
0D168ZA  
0D168ZB  
0D168ZL  
  
 **To describe either laparoscopic or open BPD with DS or GRDS, _one_ code
from _each_ of the following three _groups_ must be on the claim:**  
  
 **Group 1:**  
0DB60Z3  
0DB60ZZ  
0DB63Z3  
0DB63ZZ  
0DB67Z3  
0DB67ZZ  
0DB68Z3  
  
**Group 2:**  
One code from Groups A-C below is required.  
  
Group A:  
0DB80ZZ  
0DB90ZZ  
0DBB0ZZ  
  
Group B:  
0D160ZB  
  
Group C:  
0F190Z3  
  
**Group 3:**  
0D19079  
0D1907A  
0D1907B  
0D190J9  
0D190JA  
0D190JB  
0D190K9  
0D190KA  
0D190KB  
0D190Z9  
0D190ZA  
0D190ZB  
0D19479  
0D1947A  
0D1947B  
0D194J9  
0D194JA  
0D194JB  
0D194K9  
0D194KA  
0D194KB  
0D194Z9  
0D194ZA  
0D194ZB  
0D19879  
0D1987A  
0D1987B  
0D198J9  
0D198JA  
0D198JB  
0D198K9  
0D198KA  
0D198KB  
0D198Z9  
0D198ZA  
0D198ZB  
0D1A07A  
0D1A07B  
0D1A0JA  
0D1A0JB  
0D1A0KA  
0D1A0KB  
0D1A0ZA  
0D1A0ZB  
0D1A47A  
0D1A47B  
0D1A4JA  
0D1A4JB  
0D1A4KA  
0D1A4KB  
0D1A4ZA  
0D1A4ZB  
0D1A87A  
0D1A87B  
0D1A8JA  
0D1A8JB  
0D1A8KA  
0D1A8KB  
0D1A8ZA  
0D1A8ZB  
0D1A8ZH  
0D1B07B  
0D1B0JB  
0D1B0KB  
0D1B0ZB  
0D1B47B  
0D1B4JB  
0D1B4KB  
0D1B4ZB  
0D1B87B  
0D1B8JB  
0D1B8KB  
0D1B8ZB  
0D1B8ZH  
  
**NOTE:** There is no distinction between open and laparoscopic BPD with DS or
GRDS for the inpatient setting. For either approach, one code from each of the
above three groups must appear on the claim to be covered.  
  
 **Nationally Non-Covered Procedures**  
  
For services on or after February 21, 2006, Medicare (CMS) has determined that
the following bariatric surgery procedures are not reasonable and necessary
for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01):  
 Open adjustable gastric banding (Billed with a Not Otherwise Classified
(NOC) code)  
 Open sleeve gastrectomy;  
 Laparoscopic sleeve gastrectomy (prior to June 27, 2012);  
 Open and laparoscopic vertical banded gastroplasty;  
 Intestinal bypass surgery; and,  
 Gastric balloon for treatment of obesity.