2018 BARIATRIC SURGERY MEDICARE …

1 2020 BARIATRIC SURGERY MEDICARE REIMBURSEMENT CODING GUIDEE ffective January 1, 2020 CPT Coding and CY 2020 MEDICARE National Averages for BARIATRIC SURGERY for Physcians, Hospital Outpatient and Ambulatory SURGERY CentersPHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4 PROCEDURECPT CODE1/HCPCS CODE2 CODE DESCRIPTIONMEDICARE NATL AVGFACILITY SETTINGAPC AND APC DESCRIPTIONMEDICARENATL AVGMEDICARE NATL AVGG astric Bypass, Laparoscopic 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)$1,829 Inpatient only, not reimbursed for hospital outpatient or ASC 43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption$1,947 Inpatient only, not reimbursed for hospital outpatient or ASC Gastric Band, Laparoscopic543770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)$1,1845362, Level 2 Laparoscopy $8,413N/A for ASCG astric Band, Revision and Removal of Band, Laparoscopic643771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only$1,345 Inpatient only, not reimbursed for hospital outpatient or ASC 43772 Laparoscopy, surgical, gastric restrictive procedure.

2 Removal of adjustable gastric restrictive device component only$1,0015303, Level 3 Upper GI Procedures$2,999N/A for ASC43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only$1,3455361, Level 1 Laparoscopy$4,834N/A for ASC43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components$1,0115303, Level 3 Upper GI Procedures$2,999N/A for ASCG astric Band, Revision and Removal of Port 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only$3825055, Level 5 Skin Procedures$2,977$1,50443887 Gastric restrictive procedure, open; removal of subcutaneous port component only$3445054, Level 4 Skin Procedures$1,623$82043888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only$4865055, Level 5 Skin Procedures$2,977$1,504 Adjustment of Band Diameter7S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of salineN /ASleeve Gastrectomy, Laparoscopic 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)$1,175 Inpatient only, not reimbursed for hospital outpatient or ASC Vertical-Banded Gastroplasty, Open43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity.

3 Vertical-banded gastroplastyNot covered by MEDICARE PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4 PROCEDURECPT CODE1/HCPCS CODE2 CODE DESCRIPTIONMEDICARE NATL AVGFACILITY SETTINGAPC AND APC DESCRIPTIONMEDICARENATL AVGMEDICARE NATL AVGO ther Gastric Restrictive Procedure, Open43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty$1,350 Inpatient only, not reimbursed for hospital outpatient or ASC Biliopancreatic Diversion (without Duodenal Switch) 43632 Gastrectomy, partial, distal; with gastrojejunostomy $2,142 Inpatient only, not reimbursed for hospital outpatient or ASC Biliopancreatic Diversion with Duodenal Switch 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)$2,050 Inpatient only, not reimbursed for hospital outpatient or ASC Gastric Bypass, Open43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy$1,710 Inpatient only, not reimbursed for hospital outpatient or ASC 43847 Gastric restrictive procedure.

4 With gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption$1,902 Inpatient only, not reimbursed for hospital outpatient or ASC Revision, Gastric Restrictive Procedure843848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)$2,039 Inpatient only, not reimbursed for hospital outpatient or ASC Other Revision943850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy$1,716 Inpatient only, not reimbursed for hospital outpatient or ASC 43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy$1,781 Inpatient only, not reimbursed for hospital outpatient or ASC 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy$1,722 Inpatient only, not reimbursed for hospital outpatient or ASC 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy$1,802 Inpatient only, not reimbursed for hospital outpatient or ASC Robotic Assistance7S2900 Surgical techniques requiring use of robotic surgical systemN /AReferences1 2020 CPT Professional Edition.

5 American Medical Association. 2 Centers for MEDICARE and Medicaid Services. Healthcare Common Procedure Coding System. Centers for MEDICARE & Medicaid Services. MEDICARE Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; MEDICARE Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; MEDICARE Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule.

6 And Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule; Final Rule, Federal Register (84 Fed. Reg. No. 221 (62568-63563) 42 CFR Parts 403, 409, 410, 411, 414, 415, 416, 418, 424, 425, 489 and 498. Published November 15, 2019. 4 Centers for MEDICARE & Medicaid Services. MEDICARE Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children s Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity To Apply for Available Slots.)

7 Final Rule, Federal Register (84 Fed. Reg. No. 218 61142 - 61492) 42 CFR Parts 405, 410, 412, 414, 416, 419, and 486. Published November 12, 2019. Addendum B, AA. See also Correction Notice CMS-1717-CN; Published January 3, 2020. Addendum B, Code 43770 is for placement of both components. Placement of individual components is reported differently by physicians and hospital. Physicians may report 43770 with reduced services modifier -52; codes submitted with modifier -52 generally receive reduced payment after individual review of physician documentation required by the payer. Hospitals may report 43770 with hospital modifier -74, discontinued procedure after administration of anesthesia, which is also appended to indicate partially reduced procedures performed under anesthesia; codes submitted with modifier -74 continue to pay at 100% of the rate.

8 6 For removal and replacement of both gastric band and subcutaneous port, assign code 43659, unlisted laparoscopy procedure, stomach. For physicians, code 43659 is contractor priced. For hospital outpatient, code 43659 maps to APC 5361, Level 1 Laparoscopy, MEDICARE national average $4,834. Procedures which use unlisted codes such as 43659 are not permitted by MEDICARE in ASCs. CPT Assistant April 2006. SURGERY : Digestive System -- BARIATRIC Surgery7 HCPCS II S-codes cannot be reported to MEDICARE . They are used only by non- MEDICARE payers, which cover and price them according to their own Code 43848 is used for open revision or reversal of gastric restrictive procedures, eg, converting banding to gastric bypass, restapling a dehiscence of a staple restrictive line.

9 CPT Assistant May 1998. BARIATRIC SURGERY : Gastric Restrictive Procedures. 9 Although not specifically defined for BARIATRIC procedures, some payers may accept these codes for revisions of gastric bypass CODING FOR BARIATRIC SURGERY1 ICD-10-CM diagnosis codes are used by physicians, hospitals, ambulatory SURGERY centers and other providers to indicate the reason for the procedures are performed for patients who are obese. While the patients typically have associated comorbidities that should also be coded and reported, obesity remains the primary reason for the procedure. Payers may also require that a specific BMI be reported to meet coverage criteria. ICD-10-CM also provides codes specifically for complications of BARIATRIC procedures.

10 The codes displayed are representative of diagnoses and procedures that are associated with BARIATRIC SURGERY . Other diagnosis and procedure codes may also be available. Providers should check with their coding advisors and payers for additional or alternate Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) DIAGNOSIS CODESCODE DESCRIPTIONO besity (severe) obesity due to excess calories obesity due to excess obesity mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI) , mass index (BMI)