Superb Coding Tips for Bariatric Surgery sleeve procedure

bariatric surgery sleeve procedure
Gastric Banding (Photo credit: Wikipedia)

What is Bariatic Surgery?

Bariatric surgery is the procedure done on obese people to help them lose weight by reduction in stomach size that result in reduced food intake and absorption. The most widely used bariatric procedures are the, Roux-en-Y gastric bypass (43644-43645 and 43846-43847) and biliopancreatic diversion with duodenal switch (43845). Also checkout the basic procedure done when patient is unable to eat or swallow food properly, physician place a Gastrostomy tube to feed them.

Roux-en-Y Won't Involve Gastrectomy

you can usually identify a Roux-en-Y procedure by the inclusion of the term "Roux-en-Y" in the operative report. This is the most common type of bariatric procedure surgeons now perform.
CPT includes two codes to describe open Roux-en-Y procedures:
43846 -- Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 -- ... with small intestine reconstruction to limit absorption.

Code 43846 involves partitioning off a small section of the stomach (usually with staples) and dividing the small intestines. The surgeon attaches one portion of the small bowel to the new stomach pouch and uses the other (distal) portion of the bowel to create a "bypass" before rejoining it to the main portion of the small intestine. This restricts food intake and limits absorption.

Measurements matter: Code 43847 involves a more extensive rerouting of the small intestine (longer than 150-cm limb) to limit absorption further.

Tip: Although the surgeon resects the stomach, she does not remove any portion of it (gastrectomy) during 43846-43847. This is one way to differentiate these procedures from biliopancreatic diversion and biliopancreatic diversion with duodenal switch.

For Laparoscopic Procedures, Turn to 43644-43645

If the surgeon performs a Roux-en-Y bypass using the endoscope rather than using an open incision from the breastbone to the navel, you should turn to 43644 (Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less]) and 43645 (... with gastric bypass and small intestine reconstruction to limit absorption). These codes are identical to 43846 and 43847, except that they describe a laparoscopic approach.

Remember: You should never report the open and laparoscopic codes for the same procedure. If the surgeon converts a laparoscopic procedure to an open procedure, you should report the open procedure code only (see below for more information).

Biliopancreatic Diversion Includes Gastrectomy

you can identify biliopancreatic diversion with duodenal switch because it involves gastrectomy (removal of a portion of the stomach) while preserving the pylorus and a short (2- to 4-cm) section of the duodenum. During Roux-en-Y procedures as described above, the surgeon completely bypasses the duodenum.

The appropriate code to describe biliopancreatic diversion with duodenal switch is 43845
(Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy [50 to 100 cm common channel] to limit absorption [biliopancreatic diversion with duodenal switch]).

The "switch" is essential: Biliopancreatic diversion with duodenal switch (DS) differs from simple biliopancreatic diversion (BPD), which is not a covered procedure for Medicare. Specifically, whereas the BPD involves an anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the duodenum and the intestine. More specifically, the DS maintains the presence of the pylorus.

Tip: If the op note is unclear, ask. Don't hesitate to consult with the surgeon if the documentation is unclear as to the surgery's nature.

Don't Forget Separately Reportable Procedures

Surgeons often remove the appendix during bariatric surgery. You may report the appendix removal separately using +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure] [List separately in addition to code for primary procedure]) -- as long as medical necessity supports the procedure.

Surgeons may remove the appendix as a preventive measure during bariatric surgery, but unless the appendix appears abnormal (with scarring and/or old inflammatory changes, for example), the removal is incidental, and you should not report +44955 separately.

Cholecystectomy follows similar guidelines: The same rules apply if the surgeon performs cholecystectomy -- which is also common during bariatric surgery.

If the patient has cholelithiasis (gallstones) or cholecystitis (an inflamed gallbladder) for instance, you may legitimately report a separate cholecystectomy (47600).

Laparoscopic Banding Gastric Restrictive Procedures

Laparoscopic gastric restrictive surgery is reported with 43770 (Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device [e.g., gastric band and subcutaneous port components]).

How it works: During the procedure, the surgeon -- using laparoscopic techniques -- places an adjustable silicone band just below the gastroesophageal junction. The band connects to an access port into which the surgeon may inject (or aspirate) saline to expand (or contract) the band and effectively manipulate stomach size (and thus, control appetite suppression, satiety, and weight loss).

Because the surgery requires the physician to place both the adjustable band and subcutaneous port, CPT has included several companion codes for 43770 to describe subsequent revision or removal of the individual components, including:

43771 -- ... revision of adjustable gastric restrictive device component only
43772 -- ... removal of adjustable gastric restrictive device component only
43773 -- ... removal and replacement of adjustable gastric restrictive device component only
43774 -- ... removal of adjustable gastric restrictive device and subcutaneous port components.

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Overweight Alone Won't Ensure Coverage
not every patient will qualify for Medicare coverage of bariatric procedures.
Most substantially, Medicare will not cover bariatric surgery in patients who only have an obesity diagnosis. Instead, CMS will only provide coverage for patients who present with various comorbidities, including hypertension, type-II diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain types of cancers.
Specifically, CMS guidelines dictate, "Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with the medical treatment of obesity."
Tip: You can specify a patient's body mass index using diagnostic V code series V85.x.
Additionally, the agency determined that the benefit of bariatric surgery "can only be assured in facilities that do large numbers of these procedures performed by highly qualified surgeons." Specifically, such facilities must obtain certification from either the American College of Surgeons or the American Society of Bariatric Surgery.

You should not report 43772 and 43773 for the same session. Removal and replacement of the gastric restrictive device (43773) includes removal as described by 43772.

Don't Confuse Revisions and Adjustments

although appropriately applying 43771-43774 is mostly self-explanatory, you must be careful to make one distinction: Gastric restrictive device adjustments (by saline injection or aspiration) are not the same as revisions as described by 43771.

The physician performs adjustments routinely (generally in the office) several times a year to optimize weight loss. You should include such adjustments to the gastric restrictive device by saline injection/aspiration (which is a nonsurgical procedure) as a standard postoperative component of 43770 and 43773, according to CPT rules and the AMA's CPT Changes 2006: An Insider S View.

In other words: You cannot report a separate service for band adjustments during the primary procedures' global period.

On the other hand, gastric restrictive device revision (43771) involves laparoscopic surgery to manipulate a gastric device placed during a previous procedure. Such revisions are not routine, and a surgeon would only undertake such a procedure to manage a complication.

Modifiers, Unlisted Codes Make Up for Gaps

In two circumstances, you still cannot call on a dedicated CPT code to describe a procedure associated with laparoscopic gastric banding. These include placing either the gastric restrictive device or the subcutaneous port components only, or removing and replacing both the gastric restrictive device and subcutaneous port components.

When the surgeon places either the gastric device or port components only, you should report 43770, but append modifier 52 (Reduced services) to indicate that the surgeon did not perform the complete procedure, according to CPT guidelines.

In the second case (when the surgeon removes and replaces both the gastric restrictor and subcutaneous port components), you must reach for 43659 (Unlisted laparoscopy procedure, stomach), CPT says.

Open Codes Complement Laparoscopic Procedures

Code 43848 describes revision; open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure). As directed by the code descriptor, you should apply 43848 for all open revisions of gastric bypass procedures, except those involving gastric bypass restrictors.

Parenthetical references direct you to report 43770-43774 (explained above) for laparoscopic revision of gastric bypass restrictive devices and 43886-43888 (explained below) for open revisions of gastric bypass restrictors.
The open codes mirror somewhat their laparoscopic counterparts 43771-43774, as follows:
43886 -- Gastric restrictive procedure, open; revision of subcutaneous port component only
43887 -- ... removal of subcutaneous port component only
43888 -- ... removal and replacement of subcutaneous port component only.
Just as you should not report 43772 (lap removal of port) and 43773 (lap removal and replacement of port) for the same session, you should not report 43887 (open removal of port) and 43888 (open removal and replacement of port) together. Code 43888 includes the work involved in 43887.

Don't Report Lap and Open Codes Together

you should observe correct coding conventions by not reporting both a laparoscopic procedure and the analogous open procedure for the same session. Instead, you should report only the open procedure.
Example: You should not report 43888 with 43774, according to CPT, because these codes describe different methods of achieving the same ends (removal and replacement of the subcutaneous port component). If the surgeon attempts the procedure using the laparoscope but converts to an open procedure, report 43888 only.

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