Article - Billing and Coding: Bariatric Surgery Coverage (A53026)

CMS National Coverage PolicyN/AArticle TextBackgroundCoverage of bariatric surgery is described in the Internet Only Manual (IOM)Medicare National Coverage Determinations Manual, Publication 100-03, Section 100.1Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid ObesityandMedicare 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 GastrectomyTo 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 patients 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 includesALLof 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 beneficiarys primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgeryc. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirementsd. a nutritional evaluation by a physician or registered dietician.Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZNationally Covered Inpatient Facility ICD-10-CM Procedure CodesFor 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:0DB64Z30DV64CZ0D164790D1647A0D1647B0D1647L0D164J90D164JA0D164JB0D164JL0D164K90D164KA0D164KB0D164KL0D164Z90D164ZA0D164ZB0D164ZLOther gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes:0D160790D1607A0D1607B0D1607L0D160J90D160JA0D160JB0D160JL0D160K90D160KA0D160KB0D160KL0D160Z90D160ZA0D160ZB0D160ZL0D168790D1687A0D1687B0D1687L0D168J90D168JA0D168JB0D168JL0D168K90D168KA0D168KB0D168KL0D168Z90D168ZA0D168ZB0D168ZLTo describe either laparoscopic or open BPD with DS or GRDS,onecode fromeachof the following threegroupsmust be on the claim:Group 1:0DB60Z30DB60ZZ0DB63Z30DB63ZZ0DB67Z30DB67ZZ0DB68Z3Group 2:One code from Groups A-C below is required.Group A:0DB80ZZ0DB90ZZ0DBB0ZZGroup B:0D160ZBGroup C:0F190Z3Group 3:0D190790D1907A0D1907B0D190J90D190JA0D190JB0D190K90D190KA0D190KB0D190Z90D190ZA0D190ZB0D194790D1947A0D1947B0D194J90D194JA0D194JB0D194K90D194KA0D194KB0D194Z90D194ZA0D194ZB0D198790D1987A0D1987B0D198J90D198JA0D198JB0D198K90D198KA0D198KB0D198Z90D198ZA0D198ZB0D1A07A0D1A07B0D1A0JA0D1A0JB0D1A0KA0D1A0KB0D1A0ZA0D1A0ZB0D1A47A0D1A47B0D1A4JA0D1A4JB0D1A4KA0D1A4KB0D1A4ZA0D1A4ZB0D1A87A0D1A87B0D1A8JA0D1A8JB0D1A8KA0D1A8KB0D1A8ZA0D1A8ZB0D1A8ZH0D1B07B0D1B0JB0D1B0KB0D1B0ZB0D1B47B0D1B4JB0D1B4KB0D1B4ZB0D1B87B0D1B8JB0D1B8KB0D1B8ZB0D1B8ZHNOTE: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 ProceduresFor 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.