Obesity and diabetes are common conditions for which medical billing companies help physicians submit claims for payment. As obesity is a major independent risk factor for developing diabetes, the American Society for Metabolic and Bariatric Surgery (ASMBS) refers to them as twin epidemics. According to the ASMBS, more than 90% of people with type 2 diabetes are overweight or obese.
There are many ways to address morbid obesity and promote weight loss, and bariatric surgery is a proven option. Recent studies indicate that bariatric surgery can help people with diabetes by enabling weight loss and reducing the risk of heart attack and stroke. In fact, in 2016, the American Diabetes Association officially approved bariatric surgery as an effective treatment for some patients with type 2 diabetes.
Different Types of Bariatric Surgical Procedures
Providers can get reimbursed for different types of bariatric procedures that are proven and/or medically necessary in adults for treating extreme obesity. These include:
- Gastric bypass (Roux-en-Y; gastrojejunal anastomosis) – Gastric restriction and malabsorption; reduction of the stomach to a small gastric pouch (30 cc); open or laparoscopic
- Adjustable gastric banding (laparoscopic adjustable silicone gastric banding) – Gastric restriction only; a band creating a gastric pouch with a capacity of approximately 15 to 30 ccs encircles the uppermost portion of the stomach; laparoscopic only
- Gastric sleeve procedure – Sleeve resection of the stomach; open or laparoscopic
- Vertical banded gastroplasty – Gastric restriction only; the upper part of the stomach is stapled (rarely performed)
- Biliopancreatic bypass (Scopinaro procedure) – reduces the size of the stomach through surgical horizontal stapling
- Biliopancreatic diversion with duodenal switch – in this 2-stage operation, a smaller, tubular stomach pouch is first created by removing a portion of the stomach and then the small intestine is connected to the outlet of the newly created stomach.
Coding Bariatric Surgery
Z98.84 is a billable ICD 10 code used to specify a diagnosis of bariatric surgery status. Here is a list of CPT codes used to report bariatric procedures in 2018:
Laparoscopic Gastric Bypass
- 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150cm or less)
- 43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
Laparoscopic Gastric Banding
- 43770 Laparoscopy, surgical, gastric restrictive procedure: placement of adjustable gastric restrictive device (gastric band and subcutaneous port components) (For individual component placement, report 43770 with modifier 52)
- 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only
- 43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
- 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
- 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
Laparoscopic Sleeve Gastrectomy
Miscellaneous Gastric Procedures (including revisions)
- 43659 Unlisted laparoscopy procedure, stomach
- 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty (Not Covered By Medicare)
- 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
- 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)
- 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150cm or less) Roux-en-Y gastroenterostomy
- 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
- 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
- 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy
- 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy
- 43886 Gastric reconstructive procedure, open; revision of subcutaneous port component only
- 43887 Gastric reconstructive procedure, open; removal of subcutaneous port component only
- 43888 Gastric reconstructive procedure, open; removal and replacement of subcutaneous port component only
- 43999 Unlisted procedure, stomach
Reimbursement Challenges
Obtaining reimbursement for bariatric surgery is challenging. Medicare and commercial insurance companies cover bariatric surgical procedures for members who meet specific criteria. Coverage also depends on Local Coverage Determinations and payers’ policies, the member’s specific benefit plan document, and applicable laws that may require coverage for a specific service. Private insurers also have many restrictions and even exclusions. For instance, United Healthcare requires that a member must meet the following criteria to get coverage for bariatric procedures that are proven and/or medically necessary:
- Class III obesity, (Extreme Obesity), [Body Mass Index (BMI) > 40 kg/m2 ]; or
- Class II obesity (BMI 35-39.9 kg/m2 ) in the presence of one or more of the following co-morbidities:
- Type 2 diabetes; or
- Cardiovascular disease (e.g., stroke, myocardial infarction, poorly controlled hypertension (systolic blood pressure greater than 140 mm Hg or diastolic blood pressure 90 mm Hg or greater, despite pharmacotherapy); or
- History of coronary artery disease with a surgical intervention such as cardiopulmonary bypass or percutaneous transluminal coronary angioplasty; or
- Obstructive Sleep Apnea (OSA) confirmed on polysomnography with an AHI or RDI of >30; or
- History of cardiomyopathy
The individual must also meet the following criteria:
- Documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 6 months;
- Psychosocial behavioral evaluation to provide screening and identification of risk factors or potential postoperative challenges that may contribute to a poor post-operative outcome. Surgeons who perform bariatric surgery need to submit accurate documentation that meets payer guidelines. Therefore, in addition to medical billing and coding services, bariatric insurance verification and pre authorization services are crucial to confirm patient’s coverage for the submission of error-free claims.
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