MIR-2007 06AB, June 2007

Clarification of Bariatric Surgery Billing Requirements Issued in CR 5013 (MM5477 Revised)

Note: This article was revised on May 4, 2007, to clarify the types of Medicare contractors that will deny certain claims as opposed to rejecting claims.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to carriers, Fiscal Intermediaries (FI), or Part A/B Medicare Administrative Contractors (A/B MAC) for bariatric surgery related services provided to Medicare beneficiaries

Provider Action Needed

Impact to You
This article is based on Change Request (CR) 5477 which clarifies the claims processing instructions contained in CR 5013 (Transmittals R931CP and R54NCD; titled Bariatric Surgery for Morbid Obesity).

What You Need to Know
On April 28, 2006, the Centers for Medicare & Medicaid Services (CMS) issued CR 5013 providing coverage for certain bariatric surgical procedures. CMS found that some claims not involving bariatric surgery are being denied in error while some covered bariatric surgery claims are being held rather than paid.

What You Need to Do
See the Background and Additional Information sections of this article for further details regarding these clarifications.

Background
On April 28, 2006, CMS issued CR 5013 (Transmittals R931CP and R54NCD, dated April 28, 2006)) providing coverage for certain bariatric surgical procedures. This national coverage determination (NCD) is contained in Section 100.1 of the Medicare NCD Manual.

It came to the attention of the CMS that this NCD is not being implemented uniformly, and CMS found that:

• Some claims not involving bariatric surgery are being denied in error, and
• Some covered bariatric surgery claims are being held rather than paid.

Therefore, CMS is issuing CR5477 to clarify the claims processing instructions contained in CR 5013.

Certain bariatric surgery procedures for treatment of comorbidities associated with morbid obesity are considered reasonable and necessary under the Social Security Act (Section 1862(a)(1)(A)) if the following conditions are satisfied:

1. The Medicare beneficiary:

• Has a body-mass index (BMI) >35,
• Has at least one comorbidity related to obesity (such as diabetes or hypertension), and
• Has been previously unsuccessful with medical treatment for obesity.

2. The procedure is performed in an approved facility listed at http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp on the CMS Web site.

Note: The NCD itself has not changed and treatments for obesity alone are noncovered.

The following revisions to the Medicare Claims Processing Manual (Publication 100-04; Chapter 32) provide guidance for bariatric surgery claims payment:

ICD-9 Diagnosis Codes for BMI =35

Claims must be submitted to carriers or A/B MACs with the ICD-9-CM diagnosis code of 278.01 for morbid obesity and one of the appropriate Healthcare Common Procedure Coding System (HCPCS) codes as follows:

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, surgical, gastric restrictive procedure with gastric bypass and small intestine reconstruction to limit absorption

43845 - Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy, and ileolieostomy (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

43847 - Gastric restrictive procedure with small intestine reconstruction to limit absorption

Medicare FIs and A/B MACs will accept bariatric surgery claims billed by institutional providers with and ICD-9-CM diagnosis code of 278.01 for morbid obesity and one of the following ICD-9-CM procedure codes:

44.38 - Laparoscopic gastroenterostomy; bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy; laparoscopic gastrojejunostomy without gastrectomy NEC

44.39 - Other gastroenterostomy; bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy; gastrojejunostomy without gastrectomy NOS

44.95 - Laparoscopic gastric restrictive procedure; adjustable gastric band and port insertion

Note: If ICD-9-CM diagnosis code 278.01 is present, but one of the listed ICD-9-CM procedure codes or HCPCS codes is not present, then the Medicare contractor will determine the claim is not for bariatric surgery and will process the claim accordingly. Also, if one of the ICD-9-cm procedure codes is present without ICD-9-CM diagnosis code 278.01, then the claim is not for bariatric surgery, and the contractor will process the claim accordingly.

Also, to describe either laparoscopic or open biliopancreatic diversion with duodenal switch (BPD/DS), claims must contain all three of the following codes:

43.89 - Other; partial gastrectomy with bypass gastrogastrostomy; sleeve resection of stomach

45.51 - Isolation of segment of small intestine; isolation of ileal loop; resection of small intestine for interposition

45.91 - Small-to-small intestinal anastomosis

Claims submitted to FIs or A/B MACs must contain International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code reported as specified according to the following conditions:

• The Medicare contractor will pay the bariatric surgery claim if ICD-9-CM diagnosis code 278.01 (Morbid obesity; severe obesity) is present and all of the following are present:

- At least one of the specified ICD-9-CM diagnosis codes for BMI =35,

- An appropriate procedure code(s) as listed in the Medicare Claims Processing Manual (Pub. 100-04), Chapter 32, Sections 150.2 and 150.3,

- An appropriate obesity-related comorbid diagnosis code(s), and

- The procedure was performed in an approved facility.

• The Medicare contractor will deny the bariatric surgery claim if ICD-9-CM diagnosis code 278.01 is present, but any of the following are not present:

- At least one of the specified ICD-9-CM diagnosis codes for BMI =35,

• An appropriate procedure code(s) as listed in the Medicare Claims Processing Manual (Pub. 100-04), Chapter 32, Sections 150.2 and 150.3,
• An appropriate obesity-related comorbid diagnosis code(s), and
• The procedure was performed in an approved facility.

Note: The term, “deny,” rather than “reject” is used because beneficiaries and providers are entitled to appeal rights.

• If ICD-9-CM diagnosis code 278.01 is not present, the contractor will adjudicate the non-bariatric surgery claim based on the ICD-9-CM procedure codes listed on the claim.

Noncovered HCPCS/ICD-9-CM Procedure Codes
Contractors (carriers and B MACs) will deny bariatric surgery claims when:

• Billed with HCPCS procedure code 43842 (Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty) when used for open vertical banded gastroplasty. Note: This code was included in the April 2006 update of the Medicare Physician Fee Schedule Database and the July update of the Medicare Outpatient Code Editor.
• Billed with Not Otherwise Classified (NOC) HCPCS code 43999 when used for the following noncovered procedures: (When this NOC coded is used, the procedure should be described.)

- Laparoscopic vertical banded gastroplasty

- Open sleeve gastrectomy

- Laparoscopic sleeve gastrectomy

- Open adjustable gastric banding

Contractors (FIs and A MACs) will reject bariatric surgery claims when:

• Billed with principal ICD-9-CM diagnosis code 278.01 and ICD-9-CM procedure code 44.68 when used for the following noncovered procedures:

- Open adjustable gastric banding

- Laparoscopic vertical banded gastroplasty.

Note: Carriers, FIs, or A/B MACs will use Claim Adjustment Reason Code 50 when denying/rejecting claims for noncovered bariatric surgery procedures, reason code 58 when payment is denied due to performing the surgery at an unapproved facility, and reason code 167 when denying the claim because the patient did not meet the conditions for coverage. Appeal rights will be afforded to all parties.

• Billed with principal ICD-9-CM diagnosis code 278.01 and ICD-9 procedure code 44.69 when used for the noncovered procedure, Open vertical banded gastroplasty.
• Billed with principal ICD-9-CM diagnosis code 278.01 and ICD-9 procedure code 43.89 when used for the following noncovered procedures:
• Open sleeve gastrectomy
• Laparoscopic sleeve gastrectomy.

Additional Information
The official instruction, CR5477, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1233CP.pdfon the CMS Web site. The manual revisions to the Medicare Claims Processing Manual (Pub. 100-04; Chapter 32) included as an attachment to CR5477:

CR 5013, Transmittal R931CP and R54NCD, dated April 28, 2006, may be found at http://www.cms.hhs.gov/Transmittals/downloads/R931CP.pdf and http://www.cms.hhs.gov/Transmittals/downloads/R54NCD.pdf) on the CMS Web site.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5477 Revised
Pub. 100-4, Transmittal# R1233CP, CR# 5477
Related CR Release Date: April 27, 2007
Effective Date: February 21, 2006
Implementation Date: May 29, 2007