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What is Bariatric Surgery and When Is It Covered By Insurance?
What is Bariatric Surgery?
According to WebMD, weight loss surgeries developed due to the discovery of the results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine." After the surgeries, doctors found that these patients were losing weight leading to the first generation of gastric surgeries about 40 years ago.[1] Nowadays, several different techniques are being used for weight loss and are collectively referred to as Bariatric Surgeries. There are four common types of techniques being utilized in the United States [2]:
1) Adjustable Gastric Band (AGB) which decreases food intake by placing a band around the stomach
2) Roux-en-Y gastric bypass (RYGB) which restricts food intake by decreases food absorption and routing food from a small pouch in the small intestines
3) Biliopancreatic diversion with a duodenal switch (BPD-DS) which removes a piece of the stomach so individuals feel fuller faster and alters the way food is absorbed
4) Vertical sleeve gastrectomy (VSG) restricts and decreases food intake due to removal of most of the stomach.
Is Bariatric Surgery Covered By Insurance?
It is always recommended to check your appropriate state laws and individual company policies as they will vary. Nevertheless, most companies will cover bariatric surgery if the patient meets certain criteria and conditions. According to CMS, "Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity." Additionally, those procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence [3]
CMS makes the list of the facilities that meet the appropriate standards available on their website.
Other private payers adopted similar policies. For example, in order for beneficiaries to be eligible, Cigna[4] requires they:
1) Be at least 18 years of age
2) Have either a Body Mass Index (BMI) greater than or equal to 40 or a BMI between 35-39.9 with at least one clinically significant obesity-related comorbidity.
3) Demonstrated involvement in a weight loss management program in the last 12 months
4) Thorough multidisciplinary evaluation within the previous six months
How is it Billed?
The procedures codes typically used for the covered Bariatric services include: 43644, 43645, 43770, 43775, 43842, 43843, 43845, 43846, 43847. Procedures that may indicate a provider is attempting to bill for Bariatric surgeries that are considered investigational include: 43647, 43659, 43881, 43999, 64590. [5]
What Should You Look For When Auditing These Services?
- Does the medical history of the patient support the need for weight loss surgery?
- Are there diagnoses related to obesity and BMI prior to the date of surgery?
- Does the Primary Care Physician's description of the patient in the records and notations regarding the patient's weight issue correspond to the weight loss surgeon's records
- Are the providers billing for these services experiencing claim denials and resubmitting claims with changes to the codes on the claims
There are many questions to ask and pieces of information that need to be reviewed to determine if services were billed appropriately. If you need any assistance, feel free to email us at info@hcfraudshield.com.
[1] WebMD
[2] Techniques
[3] CMS NCD
[4] Cigna Policy
[5] AMA
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