Department of Health & Human Services (DHHS) Pub Medicare Claims Processing Centers for Medicare &

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1 anual ystm patmnt of alth & uman vics () Pub dica laims Pocssing nts fo dica & dicaid vics () Tansmittal 931 at: APL 28, 2006 ANGE EQUET 5013 UBJET: Billing quimnts fo Baiatic ugy fo Tatmnt of obid Obsity. UAY O ANGE: Effctiv fo svics on o aft buay 21, 2006, dica will cov opn and lapaoscopic oux-n Y gastic bypass (YGBP), lapaoscopic adjustabl gastic banding (LAGB) and opn and lapaoscopic biliopancatic divsion with duodnal switch (BP/) if ctain citia a mt and th pocdu is pfomd in an appovd facility. n addition, ffctiv fo svics pfomd on o aft buay 21, 2006, dica has dcidd that opn vtical bandd gastoplasty, lapaoscopic vtical bandd gastoplasty, opn slv gastctomy, lapaoscopic slv gastctomy and opn adjustabl gastic banding a nationally noncovd fo dica. Th dica claims pocssing manual (Publication , chapt 32, sction 150) has bn updatd to flct th nw covag. NEW/EVE ATEAL - EETVE ATE*: buay 21, 2006 PLEENTATON ATE: ay 30, 2006 fo physician claims billd to th cai, and Octob 2, 2006 fo hospital claims billd to th. isclaim fo manual changs only: Th vision dat and tansmittal numb apply to th d italicizd matial only. Any oth matial was pviously publishd and mains unchangd. owv, if this vision contains a tabl of contnts, you will civ th nw/visd infomation only, and not th nti tabl of contnts.. ANGE N ANUAL NTUTON: ( = EVE, N = NEW, = ELETE) /N/ N N N N N N N N APTE/ETON/UBETON/TTLE 32/150/Tabl of ontnts 32/150/Billing quimnts fo Baiatic ugy fo obid Obsity 32/150.1/Gnal 32/150.2/P oding fo Baiatic Pocdus 32/ /iagnosis ods fo Baiatic ugy 32/150.4/asons fo nial and dica ummay Notic (N), mittanc Advic ods and laims Adjustmnt ason od ssags 32/150.5/iscal ntmdiay Billing quimnts 32/150.6/ - 9 Pocdu ods fo Baiatic Pocdus 32/150.7/Non-ovd - 9 Pocdu od fo Baiatic ugy

2 N 32/150.8/Advanc Bnficiay Notic and NN nfomation. UNNG: No additional funding will b povidd by ; contacto activitis a to b caid out within thi Y 2006 opating budgts. V. ATTAENT: X Businss quimnts X anual nstuction onfidntial quimnts On-Tim Notification cuing Updat Notification *Unlss othwis spcifid, th ffctiv dat is th dat of svic.

3 Attachmnt - Businss quimnts Pub Tansmittal: 931 at: Apil 28, 2006 hang qust 5013 UBJET: Billing quimnts fo Baiatic ugy fo Tatmnt of obid Obsity. GENEAL NOATON A. Backgound: National ovag tminations anual (N), sctions 40.5 and 100.1, a bing modifid to b consistnt with th nw policy fo baiatic sugy. Baiatic sugy is oftn an ffctiv tatmnt fo co-mobid conditions in obs individuals who hav bn unsuccssful with xcis and dit as a mans of ducing thi co-mobid conditions. Th a two main typs of gastic sugy fo tatmnt of co-mobid conditions latd to mobid obsity: stictiv opations and malabsoptiv opations. Oth sugis combin both typs of pocdus. This spcializd sugy is only commndd fo individuals with halth concns latd to thi obsity such as coonay aty disas, diabts and slp apna. B. Policy: Th nts fo dica & dicaid vics () has dtmind that th vidnc is adquat to conclud that opn and lapaoscopic oux-n-y gastic bypass, lapaoscopic adjustabl gastic banding, and opn and lapaoscopic biliopancatic divsion with duodnal switch, a asonabl and ncssay fo dica bnficiais who hav a body-mass indx (B) > 35, hav at last on comobidity latd to obsity, and hav bn pviously unsuccssful with mdical tatmnt fo obsity. This infomation must b documntd in th patint's mdical cod. Th has dtmind that covd baiatic sugy pocdus a asonabl and ncssay only whn pfomd at facilitis that a:: (1) ctifid by th Amican ollg of ugons as a Lvl 1 Baiatic ugy nt (pogam standads and quimnts in ffct on buay 15, 2006); o (2) ctifid by th Amican ocity fo Baiatic ugy as a Baiatic ugy nt of Excllnc (pogam standads and quimnts in ffct on buay 15, 2006). A list of appovd facilitis and thi appoval dats will b listd and maintaind on th covag wbsit at and will b publishd in th dal gist. Th vidnc is not adquat to conclud that th following baiatic sugy pocdus a asonabl and ncssay; thfo, th following a non-covd fo all dica bnficiais: 1. opn vtical bandd gastoplasty; 2. lapaoscopic vtical bandd gastoplasty; 3. opn slv gastctomy; 4. lapaoscopic slv gastctomy; and 5. opn adjustabl gastic banding. Th two non-covag dtminations main unchangd - Gastic Balloon (N anual, sction ) and ntstinal Bypass (N anual, sction 100.8).

4 odification of th cunt policy on obsity, found in sction 40.5, of th N anual, will includ a fnc to th covd sugical pocdus and will mg th obsity policy with th final baiatic sugy policy. Th modifid obsity policy will ad as follows (mphasis addd to th nw languag within th policy): Obsity may b causd by mdical conditions such as hypothyoidism, ushing's disas, and hypothalamic lsions o can aggavat a numb of cadiac and spiatoy disass as wll as diabts and hyptnsion. tain dsignatd sugical svics fo th tatmnt of obsity a covd fo dica bnficiais who hav a B 35, hav at last on co-mobidity latd to obsity and hav bn pviously unsuccssful with th mdical tatmnt of obsity. Tatmnts fo obsity alon main non-covd.. BUNE EQUEENT hall" dnots a mandatoy quimnt "hould" dnots an optional quimnt quimnt Numb quimnts ontactos shall b advisd that pocdus pfomd on o aft buay 21, 2006 fo opn and lapaoscopic oux-n-y gastic bypass (YGBP), lapaoscopic adjustabl gastic banding (LAGB) and opn and lapaoscopic biliopancatic divsion (BP) with duodnal switch () a covd whn pfomd in facilitis that a: sponsibility ( X indicats th had ystm aintains Oth a i E V W (1) tifid by th Amican ollg of ugons as a Lvl 1 Baiatic ugy nt (pogam standads and quimnts in ffct on buay 15, 2006); o (2) tifid by th Amican ocity fo Baiatic ugy as a Baiatic ugy nt of Excllnc (pogam standads and quimnts in ffct on buay 15, 2006).

5 quimnt Numb quimnts ontactos shall allow th following P as of buay 21, 2006: sponsibility ( X indicats th had ystm aintains Oth a i X E V W Lapaoscopy, sugical, gastic stictiv pocdu; placmnt of adjustabl gastic band (gastic band and subcutanous pot componnts) Lapaoscopy, sugical, gastic stictiv pocdu; with gastic bypass and oux-n-y gastontostomy (oux limb 150 cm o lss) Lapaoscopy with gastic bypass and small intstin constuction to limit absoption. (o not pot in conjunction with 49320, ) Gastic stictiv pocdu with patial gastctomy, pylous-psving duodnoilostomy and iloiostomy (50 to 100 cm common channl.) to limit absoption (biliopancatic divsion with duodnal switch) Gastic stictiv pocdu, with gastic bypass fo mobid obsity; with shot limb (150 cm o lss oux-n-y gastontostomy. ( o gat than 150 cm, us 43847)( o lapaoscopic pocdu, us 43644) With small intstin constuction to limit absoption ontactos shall accpt th following -9- Pocdu ods as of buay 21, 2006: Laposcopic gastontostomy (lapaoscopic oux-n-y).

6 quimnt Numb quimnts Oth Gastontostomy (opn ouxn-y) Lapaoscopic gastic stictiv pocdu (lapaoscipic adjustabl gastic band and pot instion). NOTE: Th is not a distinction btwn lapaoscopic and opn BP with fo th inpatint stting. All of ths cods would apply to th opn appoach and must b on th claim fo th opn appoach. sponsibility ( X indicats th had ystm aintains Oth a i E V W Oth patial gastctomy solation of sgmnt of small intstin mall to small intstinal anastomosis ontactos shall not that bnficiais civing opn and lapaoscopic YGBP LAGB and opn and lapaoscopic BP/ must hav: (1) A body mass indx (B) 35; (2) At last on co-mobidity latd to obsity; and (3) Bn pviously unsuccssful with mdical tatmnt fo obsity. NOTE: Non of th V cod diagnoss (which dscib B 35) o fo mobid obsity can b th pincipl diagnosis on an inpatint dica claim ontactos shall accpt P cods 43770, 43644, 43645, 43845, and submittd with at last on of th following diagnosis cods: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4; o X

7 quimnt Numb quimnts n addition to th diagnosis cods listd in B , contactos shall nsu that an obsity latd co-mobidity such as a diabts o hyptnsion diagnosis must also b psnt on th claim ontactos shall dny claims fo th following P cods (43770, 43644, 43645, 43845, 43846, and 43847) whn submittd without th appopiat diagnosis cods ontactos shall us N # 15.4 "Th infomation povidd dos not suppot th nd fo this svic o itm." ontactos shall Us laim Adjustmnt ason od #167 "This (ths) diagnosis(s) is (a) not covd ontactos shall accpt claims with -9- pocdu cods 44.38, 44.39, 44.95, 43.89, 45.51, and 45.91, whn th following diagnosis cods a potd: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4; and n addition to th diagnosis cods listd in B , contactos shall nsu that an obsity latd co-mobidity such as a diabts o hyptnsion diagnosis must also b psnt on th claim. NOTE: Ths -9- pocdu cods will b paid by s, but a subjct to post pay viw. Any pocdu paid in th absnc of an obsity latd co-mobidity will b dnid following post pay viw ontactos shall dny claims fo th following -9- pocdu cods (44.38, 44.39, 44.95, 43.89, 45.51, and 45.91) whn submittd without th appopiat diagnosis cods. sponsibility ( X indicats th had ystm aintains Oth a i X X E V W E E

8 quimnt Numb quimnts Th dica od Edito shall b visd to pmit paymnt fo th following pocdus in an inpatint stting: sponsibility ( X indicats th a had ystm aintains Oth E V W i E Laposcopic gastontostomy (lapaoscopic oux-n-y) Oth Gastontostomy (opn ouxn-y) Lapaoscopic gastic stictiv pocdu (lapaoscipic adjustabl gastic band and pot instion). NOTE: Th is not a distinction btwn lapaoscopic and opn BP with fo th inpatint stting. All of ths cods would apply to th opn appoach and must b on th claim fo th opn appoach: Oth patial gastctomy solation of sgmnt of small intstin mall to small intstinal anastomosis ontactos shall not that opn and lapaoscopic YGBP, LAGB and opn and lapaoscopic BP/ shall b paid fo bnficiais with th covd diagnoss (s B s and ) if th facility is ctifid as spcifid at: ontactos shall dny claims if th svic was pfomd in an unappovd facility ontactos shall us N # 16.2 "Th svic cannot b paid whn povidd in this location/facility." X

9 quimnt Numb quimnts ontactos shall us laim Adjustmnt ason od 58: "Paymnt adjustd bcaus tatmnt was dmd by th pay to hav bn ndd in an inappopiat o invalid plac of svic." ontactos shall advis physicians that th bnficiay is liabl fo chags if sugy is pfomd in an unappovd facility. Th physician must hav th bnficiay sign an Advanc Bnficiay Notic (ABN) to avoid this liability ontactos shall advis hospitals, including citical accss hospitals (As), that a hospitalissud notic of noncovag (NN) must b signd by a bnficiay who wishs to hav ths svics pfomd on an inpatint basis in an unappovd facility. f th bnficiay dos not sign a NN, th facility is liabl fo th admission. NOTE: NN modl languag should b adaptd to this situation in th sction addssing th dsciption of th ca at issu. Oth contnt quimnts of a NN would still apply. Us th NN ltt most appopiat to th ovall situation ontactos shall b advisd that ffctiv fo svics on o aft buay 21, 2006, th following a non-covd fo all dica bnficiais: sponsibility ( X indicats th had ystm aintains Oth a i X E V W Opn vtical bandd gastoplasty ( P cod 43842); Lapaoscopic vtical bandd gastoplasty;* Opn slv gastctomy;* Lapaoscopic slv gastctomy;* and

10 quimnt Numb quimnts Opn adjustabl gastic banding.* sponsibility ( X indicats th had ystm aintains Oth a i E V W (* Billd with a Not Othwis lassifid {NO} cod) ontactos shall not that th following P cod is non-covd fo dica ffctiv fo svics pfomd on o aft buay 21, 2006: OE Gastic stictiv pocdu, without gastic bypass, fo mobid obsity; vtical bandd gastoplasty. NOTE: This cod is includd in th Apil 2006 updat of th dica Physician chdul atabas and th dica Outpatint od Edito July 1, ontactos shall not that th following -9- pocdu cod is non-covd fo dica ffctiv fo svics pfomd on o aft buay 21, 2006: Lapaoscopic gastoplasty (vtical bandd gastoplasty) ontactos shall dny claims fo svics billd with P 43842, o -9- cod fo any of th pocdus listd in B # and billd with an NO cod ontactos shall us N # dica dos not pay fo this itm o svic. NOTE: f billd with an NO cod, contactos shall us N#21.21 This svic was dnid bcaus dica only covs this svic und ctain cicumstancs ontactos shall us laim Adjustmnt ason od 96 "Non-covd chag(s)." E X

11 quimnt Numb quimnts Th contacto shall pay fo Baiatic ugy only whn th svics a submittd on th following typ of bill (TOB): 11X. by hospitals including As ontactos shall pay fo Baiatic ugy in ayland hospitals, on an inpatint basis accoding to th ayland tat ost ontainmnt Plan ontactos shall pay ndian alth vic () inpatint hospitals, TOB 11X, und inpatint pospctiv paymnt systm (PP) basd on th diagnosis latd goup (G) ontactos shall pay citical accss hospitals, TOB 11X, basd on 101% of th facility spcific p dim at ontactos shall pay As fo inpatint svics, TOB 11X, basd on 101% of asonabl cost ontactos shall pay inpatint hospitals, TOB 11X, und PP basd on th G ontactos nd not sach thi fils to ith tact paymnt fo claims alady paid o to toactivly pay claims. owv, contactos shall adjust claims bought to thi attntion. sponsibility ( X indicats th had ystm aintains Oth a E i V W. POVE EUATON quimnt Numb quimnts sponsibility ( X indicats th had ystm aintains Oth a i E V W

12 quimnt Numb quimnts A povid ducation aticl latd to this instuction will b availabl at shotly aft th is lasd. You will civ notification of th aticl las via th stablishd "LN atts" listsv. ontactos shall post this aticl, o a dict link to this aticl, on thi Wb sit and includ infomation about it in a listsv mssag within 1 wk of th availability of th povid ducation aticl. n addition, th povid ducation aticl shall b includd in you nxt gulaly schduld bulltin and incopoatd into any ducational vnts on this topic. ontactos a f to supplmnt LN atts aticls with localizd infomation that would bnfit thi povid community in billing and administing th dica pogam coctly. sponsibility ( X indicats th had ystm aintains Oth a i E V W V. UPPOTNG NOATON AN POBLE EGN ONEATON A. Oth nstuctions: N/A X-f quimnt # nstuctions B. sign onsidations: N/A X-f quimnt # commndation fo dica ystm quimnts. ntfacs: N/A. ontacto inancial poting /Wokload mpact: N/A E. pndncis: N/A

13 . Tsting onsidations: N/A V. EULE, ONTAT, AN UNNG Effctiv at*: buay 21, 2006 mplmntation at: ay 30, 2006 fo physician claims billd to th cai, and Octob 2, 2006 fo hospital claims billd to th. No additional funding will b povidd by ; contacto activitis a to b caid out within thi Y 2006 opating budgts. P-mplmntation ontact(s): Kat Tillman kathin.tillman@cms.hhs.gov o Eiln avidson iln.davidson@cms.hhs.gov (covag); Yvtt ousa (410) yvtt.cousa@cms.hhs.gov (cai claims); Tanka iva (410) tanka.iva@cms.hhs.gov (institutional claims) Post-mplmntation ontact(s): Os *Unlss othwis spcifid, th ffctiv dat is th dat of svic.

14 dica laims Pocssing anual hapt 32 Billing quimnts fo pcial vics Tabl of ontnts (v.931, ) Billing quimnts fo Tatmnt of Baiatic ugy fo obid Obsity Gnal P oding fo Baiatic Pocdus iagnosis ods fo Baiatic ugy asons fo nial and dica ummy Notic (N), mittanc Advic ods and laims Adjustmnt ason od ssags iscal ntmdiay Billing quimnts Pocdu ods fo Baiatic Pocdus Non-ovd -9 Pocdu od fo Baiatic ugy Advanc Bnficiay Notic and NN nfomation

15 150 - Billing quimnts fo Baiatic ugy fo Tatmnt of obid Obsity (v.931, ssud: , Effctiv: , mplmntation: ai/ ) Gnal (v.931, ssud: , Effctiv: , mplmntation: ai/ ) Effctiv fo svics on o aft buay 21, 2006, dica will cov opn and lapaoscopic oux-n-y gastic bypass (YGBP), lapaoscopic adjustabl gastic banding (LAGB) and opn and lapaoscopic biliopancatic divsion with duodnal switch (BP/) fo bnficiais who mt th following citia: hav a body-mass indx (B) 35, hav at last on co-mobidity latd to obsity, hav bn pviously unsuccssful with mdical tatmnt fo obsity, and; this mdical infomation must b documntd in th patint's mdical cod. n addition, has dtmind that covd baiatic sugy pocdus a asonabl and ncssay only whn pfomd at an appovd facility. A list of appovd facilitis may b found at uth covag guidlins can b found in th National ovag tmination anual (Publication ), ctions 40.5 and P oding fo Baiatic Pocdus (v.931, ssud: , Effctiv: , mplmntation: ai/ ) o svics on o aft buay 21, 2006, th following P cods apply fo baiatic svics: Lapaoscopy, sugical, gastic stictiv pocdu; placmnt of adjustabl gastic band (gastic band and subcutanous pot componnts) Lapaoscopy, sugical, gastic stictiv pocdu; with gastic bypass and oux-n-y gastontostomy (oux limb 150 cm o lss).

16 43645 Lapaoscopy with gastic bypass and small intstin constuction to limit absoption. (o not pot in conjunction with 49320, ) Gastic stictiv pocdu with patial gastctomy, pylouspsving duodnoilostomy and iloiostomy (50 to 100 cm common channl) to limit absoption (biliopancatic divsion with duodnal switch) Gastic stictiv pocdu, with gastic bypass fo mobid obsity; with shot limb (150 cm o lss oux-n-y gastontostomy.( o gat than 150 cm, us ) (o lapaoscopic pocdu, us ) With small intstin constuction to limit absoption. NOTE: Effctiv fo svics pfomd on o aft buay 21, 2006, P cod is non-covd fo dica iagnosis ods fo Baiatic ugy (v.931, ssud: , Effctiv: , mplmntation: ai/ ) ontactos shall accpt claims submittd fo baiatic sugy that hav th following diagnosis cods with th appopiat P o -9 pocdu cod potd. NOTE: Th claim must contain on of th following diagnoss along with an obsity latd co-mobidity. Body ass ndx (B) > 35: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4 obid Obsity: NOTE: Non of th V diagnosis cods fo B >35 o fo mobid obsity can b th pincipl diagnosis on an inpatint dica claim.

17 asons fo nial and dica ummay Notic (N), mittanc Advic ods and laim Adjustmnt ason od ssags (v.931, ssud: , Effctiv: , mplmntation: ai/ ) ontactos shall dny claims fo svics pfomd in an unappovd facility. Us th following N: 16.2 "This svic cannot b paid whn povidd in this location/facility." Us th following laim Adjustmnt ason od: 58 "Paymnt adjustd bcaus tatmnt was dmd by th pay to hav bn ndd in an inappopiat o invalid plac of svic." ontactos shall dny claims submittd with P cod o with an NO cod indicating that any on of th following pocdus was pfomd: Lapaoscopic vtical bandd gastoplasty; Opn slv gastctomy; Lapaoscopic slv gastctomy; and Opn adjustabl gastic banding. Us th following N: dica dos not pay fo this itm o svic. Us th following laim Adjustmnt od: 96 "Non-covd chag(s)." ontactos shall dny claims submittd fo baiatic sugy that do not contain th appopiat diagnosis cods: Us th following N: o itm Th infomation povidd dos not suppot th nd fo this svic Us th following laim Adjustmnt ason od: 167 "This (ths) diagnosis(s) is (a) not covd

18 iscal ntmdiay Billing quimnts (v.931, ssud: , Effctiv: , mplmntation: ai/ ) Th will pay fo Baiatic sugy only whn th svics a submittd on th following typ of bill (TOB): 11X. Typ of facility and stting dtmins th basis of paymnt: o svics pfomd in inpatint hospitals TOB 11X und PP paymnt is basd on th G. o svics pfomd in inpatint hospitals, TOB 11X und PP paymnt is basd on th G. o svics pfomd in citical accss hospitals, TOB 11X, paymnt is basd on 101% facility spcific p dim at. o svics pfomd in A inpatint hospitals, TOB 11X, paymnt is basd on 101% of asonabl cost Pocdu ods fo Baiatic Pocdus (v.931, ssud: , Effctiv: , mplmntation: ai/ ) o svics on o aft buay 21, 2006, th following -9 pocdus apply: Lapaoscopic gastontostomy (lapaoscopic oux-n-y) Oth Gastontostomy (opn oux-n-y) Lapaoscopic gastic stictiv pocdu (lapaoscopic adjustabl gastic band and pot instion) NOTE: Th is not a distinction btwn lapaoscopic and opn BP with fo th inpatint stting. Th following cods would apply to th opn appoach Oth patial gastctomy solation of sgmnt of small intstin mall to small intstinal anastomosis

19 Non-ovd -9 Pocdu od fo Baiatic ugy (v.931, ssud: , Effctiv: , mplmntation: ai/ ) Effctiv buay 21, 2006, th following -9 pocdu cod is non-covd fo dica Lapaoscopic gastoplasty (vtical bandd gastoplasty) Advanc Bnficiay Notic and NN nfomation (v.931, ssud: , Effctiv: , mplmntation: ai/ ) Physicians must b advisd that th physician is liabl fo chags if th sugy is pfomd in an unappovd facility, unlss th bnficiay was infomd that h o sh would b financially sponsibl pio to pfomanc fo th pocdu. Th povid must hav th bnficiay sign an advanc bnficiay notic (ABN) if th baiatic sugy is pfomd in an unappovd facility. Not that th ABN is th appopiat notic fo Pat B svics. Th NN modl languag should b adaptd to this situation in th sctions addssing: dsciption of th ca at issu if th sugy is pfomd on an inpatint basis, in an unappovd facility, to avoid bing liabl, th povid must issu a NN. Oth contnt quimnts of NN still apply. Us th NN ltt most appopiat to th ovall situation.