Diagnosis Coding All claim forms must include an ICD-9-CM diagnosis code to indicate the patient s principle diagnosis.

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1 Facility Coding Most payors use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes, established to report procedures in the hospital inpatient setting. Hospitals may report the appropriate ICD-9 diagnosis code in conjunction with the ICD-9-CM procedure code for the main surgical procedure. Payers may require additional clinical information specific to each patient to determine coverage and payment for Laparoscopic Adjustable Gastric Band (LAGB), Gastric Bypass (GB), and Sleeve Gastrectomy procedures. Diagnosis Coding All claim forms must include an ICD-9-CM diagnosis code to indicate the patient s principle diagnosis. Table 1: Primary Diagnosis Codes * Morbid Obesity 250.xx Diabetes Mellitus Sleep Apnea 401.x Essential Hypertension 462 Sore Throat Reflux Over Eating Hoarseness Wheezing Chronic Cough Regurgitation Heartburn Belching * Typically the primary diagnosis for those receiving Laparoscopic Adjustable Gastric Banding surgery Page 1 of 5

2 It is also permissible and often recommended to submit secondary diagnosis codes. Secondary diagnosis codes include V-codes, which classify circumstances other than a disease or injury into categories. V-codes associated with patients receiving Gastric Bypass surgical procedures are listed below. Table 2: Secondary Diagnosis Codes (V-codes)** V12.29 Personal history of other endocrine, metabolic, and immunity disorders V85.0 Body Mass Index less than 19, adult V85.1 Body Mass Index 19 to 24, adult V85.21 Body Mass Index 25.0 to 25.9, adult V85.22 Body Mass Index 26.0 to 26.9, adult V85.23 Body Mass Index 27.0 to 27.9, adult V85.24 Body Mass Index 28.0 to 28.9, adult V85.25 Body Mass Index 29.0 to 29.9, adult V85.30 Body Mass Index 30.0 to 30.9, adult V85.31 Body Mass Index 31.0 to 31.9, adult V85.32 Body Mass Index 32.0 to 32.9, adult V85.33 Body Mass Index 33.0 to 33.9, adult V85.34 Body Mass Index 34.0 to 34.9, adult V85.35 Body Mass Index 35.0 to 35.9, adult V85.36 Body Mass Index 36.0 to 36.9, adult V85.37 Body Mass Index 37.0 to 37.9, adult V85.38 Body Mass Index 38.0 to 38.9, adult V85.39 Body Mass Index 39.0 to 39.9, adult V85.4 Body Mass Index 40 or greater, adult V85.5 Body Mass Index, pediatric V53.90 Fitting and adjustment, unspecified device V53.99 Fitting and adjustment, other device ** Diagnosis codes in addition to the primary diagnosis such as heartburn, sore throat, or hoarseness likely will require documented evidence of these symptoms prior to approving treatment. Providers should select the most appropriate ICD-9-CM diagnosis code(s) with the highest level of detail and specificity to describe the patient s condition and ensure that the medical record supports the selected code(s). Be certain to distinguish between the primary and secondary diagnoses. Page 2 of 5

3 Procedure Coding for LAGB, GB, and Sleeve Gastrectomy Procedures In addition to the diagnosis code(s), claims must contain appropriate ICD-9-CM procedure code(s). Procedure codes that may apply to LAGB, GB, and Sleeve surgery in the hospital inpatient setting include: Table 3: Procedure Codes Laparoscopic vertical (sleeve) gastrectomy Open and other partial gastrectomy High gastric bypass Laparoscopic gastroenterostomy (bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy, gastrojujenostomy without gastrectomy NOS) Other gastroenterostomy (bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy, gastrojujenostomy without gastrectomy NOS) 44.5 Revision of gastric anastomosis Laparoscopic gastroplasty (Banding, silastic vertical banded gastroplasty (VBG))* Other repair of stomach Laparoscopic gastric restrictive procedure: adjustable gastric band and port insertion Laparoscopic revision of gastric restrictive procedure revision, or replacement of: adjustable gastric band subcutaneous gastric port device Laparoscopic removal of gastric restrictive device(s); removal of either or both adjustable gastric band, subcutaneous gastric port device Laparoscopic adjustment of size of adjustable gastric restrictive device; infusion of saline for device tightening; withdrawal of saline for device loosening Other operations of the stomach 88.1x Other X-ray of the abdomen 87.6x Other X-ray of the digestive system * Code also any synchronous laparoscopic gastroenterostomy (44.38) procedure At times complications may arise following or during surgery. Possible ICD-9-CM diagnosis codes for complications include: Table 4: Complication Diagnosis Codes Infection due to Gastric Band procedure Other complication due to Gastric Band procedure Infection due to other Bariatric procedure Other complication due to other Bariatric procedure Mechanical complications due to other implant and internal device, not elsewhere classified Infection and inflammatory reaction due to internal prosthetic device, implant, and graft Other complications due to unspecified device, implant, and graft Other digestive system complication Page 3 of 5

4 Coding for LAGB Adjustments The 2012 surgical coding policies for laparoscopic surgical codes advise, Typical postoperative follow-up care after gastric restriction using the adjustable gastric band technique includes subsequent band adjustment(s) through the postoperative period for the typical patient. Many payers adopt the 90-day global period rules and may not pay separately for band adjustments within the 90-day global surgical period. Currently, there is no CPT billing code to describe band adjustments specifically. To report the injection of saline into the port, there is one possible coding option: S2083 (adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline). The specific code required to describe LAGB adjustments will vary by payer. Medicare does not accept S2083. Private commercial coding requirements will vary by payer and, in some cases, by plan type. Medicaid coding rules will vary by state. When in-office imaging systems and/or fluoroscopy-guided needle placement is used, appropriate imaging procedure codes should be reported. The following table describes potential coding for LAGB adjustments and imaging procedure codes for use when those techniques are used in association with adjustment procedures. Table 5: Possible Coding for LAGB Adjustments 2012 Medicare Payment 2 S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline Carrier Priced * Fluoroscopic guidance for needle placement (e.g., biopsy aspiration, injection, localization device) $ * Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB *For select imaging procedures, the Medicare payment for when the technical component only (indicated by -26) is billed will be capped at the payment paid for imaging services rendered in the hospital outpatient setting. $34 Coding for Miscellaneous Supplies Used During LAGB Adjustments Miscellaneous supplies such as saline and syringes can be reported, but payment is commonly bundled into reimbursement for the primary procedure. Coding and payment for miscellaneous band adjustment supplies will vary by payer. Table 3: Possible Coding for Miscellaneous Supplies Associated with LAGB Adjustments A4208 A4215 J2912 Syringe with needle, sterile 3 cc, each Needle, sterile, any size, each Injection, Sodium Chloride, 0.9%, 2 ml Page 4 of 5

5 Coding for Evaluation and Management (E/M) Follow-up surgical visits are critical for LAGB patients. As discussed above, the postsurgical 90-day global period includes one postoperative E/M visit. However, by nature of the procedure, it is necessary to evaluate patients for the need to perform adjustments based on signs and symptoms described by the patient during a follow-up office visit. The standard rules for E/M coding apply when assessing the need for adjustments for LAGB. If it is determined, on the day of the office visit, that an adjustment is needed, the adjustment can be reported using one of the recommended codes (90779 or S2083), depending on what code the patient s insurance recognizes. Modifier -25 is used to describe the office visit as separate and identifiable from the adjustment procedure. An office visit should only be reported separately if the decision to perform an adjustment was made during the office visit. If the adjustment was planned in advance, only the adjustment procedure should be billed. When reporting any level of E/M service, the patient s chart should include sufficient documentation to support the level of E/M service reported. The following table describes various E/M scenarios. Table 4: Evaluation and Management Coding Scenarios* E/M Scenario E/M codes established patient; used for E/M services performed by same surgeon who performed LAGB placement procedure Used when the decision to perform an LAGB adjustment is made on the same day as E/M service and is provided by the same surgeon who performed LAGB placement procedure E/M codes new patient; used for E/M services performed by a surgeon other than who performed LAGB placement procedure Used when the decision to perform an adjustment is made on the same day as E/M service provided and the surgeon who performs adjustment is different than the surgeon who performed LAGB placement procedure 2012 Medicare Payment 2 $20 - $140 $43 - $199 * Medicare guidelines stipulate if any other physician fee schedule service is billed on the same day as no separate payment is made for Private payer and Medicaid coding and payment rules will vary by payer and state Medicaid rules. 1 All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright 2011 American Medical Association. All Rights Reserved. 2 Federal Register, Vol. 76, No. 228, Monday, November 28, 2011/Rules and Regulations. The 2012 Final Physician Reimbursement Conversion Factor = $ ; Federal Register. 3 Hospital ICD-9-CM 2010 Volumes 1, 2 & 3, 9th Revision-Clinical Modification, American Medical Association. Copyright 2011 Saunders, an imprint of Elsevier, Inc. Physicians should refer to their provider Carrier Manual for their geographic payments. The information contained in this document is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any payor. We strongly recommend that providers consult their payor organization with regard to local reimbursement policies. The information contained in this document is provided for information purposes only and represents no statement, promise or guarantee by Ethicon Endo-Surgery, Inc. concerning levels of reimbursement, payment or charge. Similarly, all CPT, HCPCS and ICD-9 codes are supplied for information purposes only and represent no statement, promise or guarantee by Ethicon Endo-Surgery, Inc. that these codes will be appropriate or that reimbursement will be made. ICD-9 is based on the official version of the World Health Organization s Ninth Revision, International Classification of Diseases. CPT codes and descriptions only are copyright 2011 American Medical Association. All Rights Reserved. CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for Medicare and Medicaid Services and various commercial payors. The content provided by the Centers for Medicare and Medicaid Services is updated frequently. It is the responsibility of the health services provider to confirm the appropriate coding required by their local Medicare carriers, fiscal intermediaries and commercial payors. Page 5 of Ethicon Endo-Surgery, Inc. All rights reserved. DSL: FC