(Medicare Claims Processing Manual)

RARC N362: The number of days or units of service exceeds our acceptable maximum.    MSN 20.5: These services cannot be paid because your benefits are exhausted at this time.   Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Contractors shall use Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  Effective for claims with dates of service on and after January 1, 2022, Medicare Contractors shall deny PR claims that exceed 72 sessions only when the - KX modifier is not submitted on the claim line.   150 - Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity  (Rev. 931, Issued:  04- 28-06, Effective:  02 -21-06, Implementation:  05- 30-06 Carrier/10-02-06 FI)   150.1 - General  (Rev. 2841, Issued: 12- 23-13, Effective: 09 -24-13, Implementation: 12- 17-13)  Bariatric Surgery for Treatment of Co -Morbid Conditions Related to Morbid Obesity   Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body- mass index  (BMI) 35, have at least one co -morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be perform ed at an approved facility. A list of approved facilities may be found at http://www.cms.gov/Medicare/Medicare -General -Information/MedicareApprovedFacilitie/Bariatric -Surgery.html   Effective for services performed on and after February 12, 2009, Medicare has determined that Type 2 diabetes mellitus is a co -morbidity for purposes of processing bariatric surgery claims.   Effective for dates of service on and after September 24, 2013, the Centers for Medicare & Medicaid Services (CMS) has removed the certified facility requirements for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.  Please note the additional national coverage determinations related to bariatric surgery will be consolidated and subsumed into Publication 100-03, Chapter 1, section 100.1. These include sections 40.5, 100.8, 100.11 and 100.14.  Open Roux- en-Y gastric bypass (RYGBP)  Laparoscopic Roux- en-Y gastric bypass (RYGBP)  Laparoscopic adjustable gastric banding (LAGB)  Open biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)   Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)  Laparoscopic sleeve gastrectomy (LSG) (Effective June 27, 2012, covered at Medicare Administrative Contractor (MAC) discretion.   150.2 - HCPCS Procedure Codes for Bariatric Surgery  (Rev. 2641, Issued: 01- 29-13, Effective: 06-27-12, Implementation: 02-28-13)  A. Covered HCPCS Procedure Codes   For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric surgery:   43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).   43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).   43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847.)   43845 - Gastric restrictive procedure with partial gastrectomy, pylorus -preserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch).   43846 - Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux- en-Y gastroenterostomy. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.)   43847 - With small intestine reconstruction to limit absorption.   43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) (Effective June 27, 2012, covered at contractors discretion.)  B. Non-Covered HCPCS Procedure Codes   For services on or after February 21, 2006, the following HCPCS procedure codes are non-covered for bariatric surgery:   43842 - Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty  NOC code 43999 used to bill for:   Laparoscopic vertical banded gastroplasty Open sleeve gastrectomy  Laparoscopic sleeve gastrectomy (for contractor non -covered instances)  Open adjustable gastric banding  150.3 - ICD Procedure Codes for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (A/MACs only)  (Rev. 11021; Issued: 10- 01-21; Effective: 10-29- 21; Implementation: 10 -29-21) Covered ICD Procedure Codes  For services on or after October 1, 2015, the following independent ICD -10 procedure codes are covered for bariatric surgery:     0D16479  Bypass Stomach to Duodenum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach   0D1647A  Bypass Stomach to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach   0D1647B  Bypass Stomach to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach   0D1647L  Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Percutaneous Endoscopic Approach   0D164J9  Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Approach   0D164JA  Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach  0D164JB  Bypass Stomach to Ileum with Synthetic Substitute, Percutaneous  Endoscopic Approach   0D164JL  Bypass Stomach to Transverse Colon with Synthetic Substitute, Percutaneous Endoscopic Approach   0D164K9  Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach   0D164KA   Bypass Stomach to Jejunum with Non- autologous Tissue Substitute,  Percutaneous Endoscopic Approach   0D164KB   Bypass Stomach to Ileum with Non- autologous Tissue Substitute,  Percutaneous Endoscopic Approach   0D164KL   Bypass Stomach to Transverse Colon with Non- autologous Tissue  Substitute, Percutaneous Endoscopic Approach   0D164Z9  Bypass Stomach to Duodenum, Percutaneous Endoscopic Approach   0D164ZA   Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach   0D164ZB   Bypass Stomach to Ileum, Percutaneous Endoscopic Approach    0D164ZL   Bypass Stomach to Transverse Colon, Percutaneous Endoscopic Approach   0D16079  Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open  Approach   0D1607A   Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Approach   0D1607B   Bypass Stomach to Ileum with Autologous Tissue Substitute, Open Approach   0D1607L   Bypass Stomach to Transverse Colon with Autologous Tissue Substitute,  Open Approach   0D160J9   Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach   0D160JA   Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach   0D160JB   Bypass Stomach to Ileum with Synthetic Substitute, Open Approach   0D160JL   Bypass Stomach to Transverse Colon with Synthetic Substitute, Open Approach   0D160K9  Bypass Stomach to Duodenum with Non- autologous Tissue Substitute,  Open Approach   0D160KA   Bypass Stomach to Jejunum with Non- autologous Tissue Substitute,  Open Approach   0D160KB   Bypass Stomach to Ileum with Non- autologous Tissue Substitute, Open Approach   0D160KL   Bypass Stomach to Transverse Colon with Non- autologous Tissue  Substitute, Open Approach   0D160Z9   Bypass Stomach to Duodenum, Open Approach   0D160ZA   Bypass Stomach to Jejunum, Open Approach   0D160ZB   Bypass Stomach to Ileum, Open Approach    0D160ZL  Bypass Stomach to Transverse Colon, Open Approach    0D16879  Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via  Natural or Artificial Opening Endoscopic   0D1687A   Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via  Natural or Artificial Opening Endoscopic   0D1687B   Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural  or Artificial Opening Endoscopic   0D1687L   Bypass Stomach to Transverse Colon with Autologous Tissue Substitute,  Via Natural or Artificial Opening Endoscopic   0D168J9  Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or  Artificial Opening Endoscopic   0D168JA   Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or  Artificial Opening Endoscopic   0D168JB   Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or  Artificial Opening Endoscopic   0D168JL   Bypass Stomach to Transverse Colon with Synthetic Substitute, Via  Natural or Artificial Opening Endoscopic   0D168K9  Bypass Stomach to Duodenum with Non- autologous Tissue Substitute,  Via Natural or Artificial Opening Endoscopic   0D168KA   Bypass Stomach to Jejunum with Non -autologous Tissue Substitute, Via  Natural or Artificial Opening Endoscopic   0D168KB   Bypass Stomach to Ileum with Non- autologous Tissue Substitute, Via  Natural or Artificial Opening Endoscopic   0D168KL   Bypass Stomach to Transverse Colon with Non -autologous Tissue  Substitute, Via Natural or Artificial Opening Endoscopic   0D168Z9  Bypass Stomach to Duodenum, Via Natural or Artificial Opening  Endoscopic   0D168ZA   Bypass Stomach to Jejunum, Via Natural or Artificial Opening  Endoscopic   0D168ZB  Bypass Stomach to Ileum, Via Natural or Artificial Opening Endoscopic   0D168ZL    0DV64CZ   Bypass Stomach to Transverse Colon, Via Natural or Artificial Opening  Endoscopic     Restriction of Stomach with Extraluminal Device, Percutaneous                              Endoscopic Approach    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 Excision of Stomach, Open Approach, Vertical  0DB60ZZ  Excision of Stomach, Open Approach  0DB63Z3 Excision of Stomach, Percutaneous Approach, Vertical  0DB63ZZ  Excision of Stomach, Percutaneous Approach  0DB67Z3 Excision of Stomach, Via Natural or Artificial Opening, Vertical  0DB67ZZ      Excision of Stomach, Via Natural or Artificial Opening  0DB68Z3 Excision of Stomach, Via Natural or Artificial Opening Endoscopic, Vertical    Group 2:  (Note: One code from A -C below is required for a correct equivalent)