Article - Billing and Coding: Surgical Management of Morbid Obesity (A57145)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33411 Surgical Management of Morbid Obesity. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CPT codes 43886, 43887 and 43888 are for open port replacement. The open port replacement procedures are associated with the non-covered open gastric restrictive procedures: adjustable gastric banding and vertical banded gastroplasty and per the National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, open port replacement procedures are also noncovered.For billing covered laparoscopic restrictive procedures that require port replacements report CPT code 43771, 43772, or 43773.CPT code 43842 is for vertical banded gastroplasty and is non-covered per NCD 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.CPT code 43843 for other than vertical-banded gastroplasty is non-covered since it is associated with the NCD 100.1 non-covered open adjustable gastric banding and open sleeve gastrectomy.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Medical record documentation must include the following: history and physical containing evidence of comorbid conditions, operative report containing a detailed procedure note, and office/progress notes documenting unsuccessful medical treatment for obesity.The medical record must substantiate presence and severity of associated organic diseases requiring the treatment of obesity documented through appropriate physiologic testing and/or imaging.The patients medical record must include documentation of all required preoperative and postoperative evaluations and interventions and all other applicable coverage provisions required as outlined in this LCD.Patients who have a history of psychiatric or psychological disorder must undergo preoperative psychological evaluation and clearance and the patients record must include documentation of the evaluation and assessment.Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation, if applicable.