Bariatric surgery, typically performed on morbidly and super-obese individuals, includes any procedure that aims to restrict food intake. Although it is highly specialized and involves significant risk, Medicare and many other carriers will not pay for it simply because the patient is obese.
Carriers are more likely to pay if the patient has other obesity-related conditions that are identified clearly in the surgeon's notes, says Anne Karl, RHIA, CPC, CCS-P, compliance coordinator with Surgical Consultants, a 10-surgeon practice in Edina, Minn. These conditions include, among others, congestive heart failure, uncontrolled diabetes mellitus and its manifestations, sleep apnea, severe arthritis, hypothyroidism and lung disease.
Code 43846 involves partitioning the stomach (usually with staples) and connecting the small intestine to the proximal stomach. Commonly known as stomach stapling, this procedure allows food to bypass most of the stomach.
Code 43847 involves rerouting of the small bowel to limit food absorption and is used to describe services that may not have been as prevalent when the code was developed, such as biliary pancreatic diversion (when the bile ducts and pancreatic ducts are reattached to the ileum so digestion of fats is significantly delayed). This procedure is often performed with a near-total gastrectomy and Roux-en-Y intestinal anastomosis with a long roux limb, which is coded 43621 (Gastrectomy, total; with Roux-en-Y reconstruction). The small bowel reconstruction and biliary pancreatic diversion is reported using 43847.
Code 43848 (Revision of gastric restrictive procedure for morbid obesity [separate procedure]) is reported when the surgeon has to operate again on a patient who has had a previous gastric restrictive procedure (for example, stomach banding or stomach stapling). Typically, the surgeon mobilizes the stomach and then performs 43846 or 43847. Complications, such as slipped bands from a banded gastro-plasty, are dealt with during the same session.
Additional Documentation May Be Required
In addition to evidence of obesity-related conditions, carriers may also want evidence that the patient has an established history of unsuccessful [...]