Local Coverage Determination (LCD): Bariatric Surgery for Morbid Obesity (L32904)

Local Coverage Determination (LCD): Bariatric Surgery for Morbid Obesity (L32904) Contractor Name Wisconsin Physicians Service Insurance Corporation Document Information LCD ID L32904 LCD Title Bariatric Surgery for Morbid Obesity AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Original Effective Date For services performed on or after 02/15/2013 Revision Effective Date For services performed on or after 09/07/2013 Revision Ending Date N/A Retirement Date ANTICIPATED 01/01/2014 Notice Period Start Date 01/01/2013 Notice Period End Date N/A CMS National Coverage Policy NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Review (LCD) process (42 CFR 405.560[b] and 42 CFR 426 [subpart D]). In addition, an administrative law judge may not

review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Publications: CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: 40.5 Treatment of Obesity CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: 100.1 Bariatric Surgery for Treatment of Morbid Obesity CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: 100.8 Intestinal Bypass Surgery CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: 100.11 Gastric Balloon for Treatment of Obesity CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 32: 150 Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity CR #6419: Subject: Surgery for Diabetes, effective 02/12/2009 Transmittal 931, CR #5013, dated April 28, 2006, Subject: Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity Transmittal 1233, CR #5477, dated April 27, 2007, Subject: Clarification of Bariatric Surgery Billing Requirements Issued in CR 5013 CR#8028: Subject; Bariatric Surgery for the Treatment of Morbid obesity National Coverage Determination, Addition of Laparoscopic Sleeve Gastrectomy (LSG, effective 06/27/2012) Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity This local coverage determination (LCD) addresses both local and national coverage and noncoverage treatment options which include various bariatric surgical interventions such as Roux-en-Y Gastric Bypass (RYGBP), Biliopancreatic Diversion with Duodenal Switch (BPD/DS), sleeve gastrectomy, etc. used to treat co morbid conditions associated with morbid obesity. The LCD also contains the ICD-9-CM codes for the co morbid conditions. Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of an excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" body weight, according to standard life insurance tables, constitutes obesity. Body mass index (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. Individuals who may be considered as candidates for gastrointestinal surgery include those with a BMI above 35 who suffer from Type II diabetes or life-threatening cardiopulmonary problems such as severe sleep apnea or obesity-related heart disease. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain. Covered Bariatric Surgery Procedures Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. 1. Open Roux-en-Y gastric bypass (RYGBP). 2. Laparoscopic Roux-en-Y gastric bypass (RYGBP). 3. Laparoscopic adjustable gastric banding (LAGB). 4. Open biliopancreatic diversion with duodenal switch (BPD/DS).

5. Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) 6. Laparoscopic sleeve gastrectomy (Effective June 27, 2012, covered at contractor s discretion) The patient must have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility. A list of approved facilities may be found on the CMS web site. Non-Covered Indications for Bariatric Surgery: Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity 1. Open vertical banded gastroplasty. 2. Laparoscopic vertical banded gastroplasty. 3. Open sleeve gastrectomy. 4. Laparoscopic sleeve gastrectomy. (for contractor non-covered instances) 5. Open adjustable gastric banding. NOC code 43999 is non-covered when used to bill for; 1. Laparoscopic vertical banded gastroplasty 2. Open sleeve gastrectomy 3. Laparoscopic sleeve gastrectomy 4. Open adjustable gastric banding Complete coverage guidelines can be found in the National Coverage Determination Manual (Publication 100-03), Sections 40.5 and 100.1. Other Comments If ICD-9-CM diagnosis code 278.01 and one of the covered ICD-9-CM procedure codes listed in 150.3 or HCPCS procedure codes listed in 150.2 are not present, the claim is not for bariatric surgery and should be processed under normal procedures. The Billing and Coding Guidelines for this LCD contains addi6tonal information for non covered services. Complete coverage guidelines can be found in the National Coverage Determination Manual (Publication 100-03), Sections 40.5 and 100.1. Laparoscopic Sleeve Gastrectomy (LSG) The laparoscopic sleeve gastrectomy is a bariatric procedure in which the surgeon removes approximately 85% of the stomach, shaping the remaining stomach into a tube or "sleeve." In the laparoscopic sleeve gastrectomy the stomach is divided along its vertical length in order to create a slender pouch. The excess stomach is removed. Prior to June 27, 2012, the laparoscopic sleeve gasatrectomy was a non covered surgical procedure for Medicare beneficiaries. On June 27, 2012 CMS issued the following decision memo: Excerpt from Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2) Decision Summary Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied. A. The beneficiary has a body-mass index (BMI) > 35 kg/m2, B. The beneficiary has at least one co-morbidity related to obesity, and C. The beneficiary has been previously unsuccessful with medical treatment for obesity.

1. Laparoscopic sleeve gastrectomy will be covered if all the requirements of the NCD, including the June 2012 Decision Memo and all its diagnoses as coded in this LCD are met. 2. HCPCS code 43775 (lap sleeve gastrectomy) was previously a Non-covered Service (N). Effective June 27, 2012 HCPCS code 43775 is Carrier Priced (C). Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 011x Hospital Inpatient (Including Medicare Part A) 013x Hospital Outpatient 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes to not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review. Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X.

036X Operating Room Services - General Classification 096X Professional Fees - General Classification CPT/HCPCS Codes Group 1 Paragraph: To be considered a bariatric surgical procedure the CPT codes contained in the list directly below must have the primary diagnosis ICD-9 code of 278.01) Note: 1. Code 43999 is only to be used for Adjustment of a gastric band. For additional information refer to Utilization Guidelines section. 2. Code 43842 is non payable per 100-04, Ch. 32 150. (Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty). Group 1 Codes: LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 43644 GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 43645 GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT 43770 OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) 43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY) GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS- 43845 PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID 43846 OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY 43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION 43999 UNLISTED PROCEDURE, STOMACH ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: Claims for any bariatric surgical procedure must include the primary diagnosis of 278.01 and one of the body mass index (BMI) codes, along with at least one of the secondary (co morbidity) diagnoses that relates to morbid obesity. Primary Obesity Diagnosis Code Group 1 Codes: 278.01 MORBID OBESITY Group 2 Paragraph: Body Mass Index Diagnosis Codes Group 2 Codes: V85.35 BODY MASS INDEX 35.0-35.9, ADULT V85.36 BODY MASS INDEX 36.0-36.9, ADULT V85.37 BODY MASS INDEX 37.0-37.9, ADULT V85.38 BODY MASS INDEX 38.0-38.9, ADULT V85.39 BODY MASS INDEX 39.0-39.9, ADULT V85.41 - V85.45 BODY MASS INDEX 40.0-44.9, ADULT - BODY MASS INDEX 70 AND OVER, ADULT Group 3 Paragraph: Co morbidity Diagnosis Codes Group 3 Codes: 250.00 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE,

NOT STATED AS DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], NOT 250.01 STATED AS DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, 250.02 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], 250.03 DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS 250.10 250.11 DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], NOT STATED AS 250.12 DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, 250.13 DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS 250.20 DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], NOT STATED AS 250.21 250.22 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, 250.23 DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS 250.30 250.31 DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], NOT STATED AS 250.32 DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, 250.33 DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], 250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS

DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS 250.41 250.42 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, 250.43 DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT 250.50 STATED AS DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS 250.51 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, 250.52 250.53 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT 250.60 STATED AS DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS 250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, 250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], 250.63 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, 250.70 NOT STATED AS DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT 250.71 STATED AS DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, 250.72 250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE],

DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT 250.80 STATED AS DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED 250.81 AS DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, 250.82 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], 250.83 DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED 250.90 AS DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], NOT STATED AS 250.91 DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, 250.92 250.93 DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], 256.31 PREMATURE MENOPAUSE 256.39 OTHER OVARIAN FAILURE 256.4 POLYCYSTIC OVARIES 256.8 OTHER OVARIAN DYSFUNCTION 256.9 UNSPECIFIED OVARIAN DYSFUNCTION 278.8 OTHER HYPERALIMENTATION 327.23 OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) 348.2 BENIGN INTRACRANIAL HYPERTENSION

401.0 MALIGNANT ESSENTIAL HYPERTENSION 401.1 BENIGN ESSENTIAL HYPERTENSION 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 402.00 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 402.10 BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 402.90 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE 403.00 STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE 403.01 STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE 403.10 I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE 403.11 V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE 403.90 STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE 403.91 STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART 404.00 FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE

AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART 404.02 FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE 404.03 AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE 404.10 AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND 404.11 WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE 404.12 AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND 404.13 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART 404.90 FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE 404.91 AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART 404.92 FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE 404.93 AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 405.01 MALIGNANT RENOVASCULAR HYPERTENSION 405.09 OTHER MALIGNANT SECONDARY HYPERTENSION 405.11 BENIGN RENOVASCULAR HYPERTENSION 405.19 OTHER BENIGN SECONDARY HYPERTENSION

405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION 405.99 OTHER UNSPECIFIED SECONDARY HYPERTENSION 416.8 OTHER CHRONIC PULMONARY HEART DISEASES 437.2 HYPERTENSIVE ENCEPHALOPATHY 454.0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER 454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION 454.8 VARICOSE VEINS OF LOWER EXTREMITIES WITH OTHER COMPLICATIONS 530.11 REFLUX ESOPHAGITIS 530.81 ESOPHAGEAL REFLUX 537.0 ACQUIRED HYPERTROPHIC PYLORIC STENOSIS INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) 560.81 (POSTINFECTION) 560.9 UNSPECIFIED INTESTINAL OBSTRUCTION 564.2 POSTGASTRIC SURGERY SYNDROMES 715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH 715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG 715.17 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING ANKLE AND FOOT 715.18 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES 715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH 715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG 715.27 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING ANKLE AND FOOT 715.28 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES

OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY 715.35 INVOLVING PELVIC REGION AND THIGH OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY 715.36 INVOLVING LOWER LEG OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY 715.37 INVOLVING ANKLE AND FOOT OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY 715.38 INVOLVING OTHER SPECIFIED SITES OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING 715.95 PELVIC REGION AND THIGH OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING 715.96 LOWER LEG OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING ANKLE 715.97 AND FOOT OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING 715.98 OTHER SPECIFIED SITES 716.85 OTHER SPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH 716.86 OTHER SPECIFIED ARTHROPATHY INVOLVING LOWER LEG 716.87 OTHER SPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT 716.88 OTHER SPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 716.95 UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH 716.96 UNSPECIFIED ARTHROPATHY INVOLVING LOWER LEG 716.97 UNSPECIFIED ARTHROPATHY INVOLVING ANKLE AND FOOT 716.98 UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES 718.05 ARTICULAR CARTILAGE DISORDER INVOLVING PELVIC REGION AND THIGH

718.07 ARTICULAR CARTILAGE DISORDER INVOLVING ANKLE AND FOOT 718.08 ARTICULAR CARTILAGE DISORDER INVOLVING OTHER SPECIFIED SITES 719.7 DIFFICULTY IN WALKING 719.85 OTHER SPECIFIED DISORDERS OF JOINT OF PELVIC REGION AND THIGH 719.86 OTHER SPECIFIED DISORDERS OF LOWER LEG JOINT 719.87 OTHER SPECIFIED DISORDERS OF ANKLE AND FOOT JOINT 719.88 OTHER SPECIFIED DISORDERS OF JOINT OF OTHER SPECIFIED SITES 722.51 DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC 722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC 722.73 INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION 722.93 OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION 724.2 LUMBAGO 724.3 SCIATICA 724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED 724.5 BACKACHE UNSPECIFIED 724.6 DISORDERS OF SACRUM 724.8 OTHER SYMPTOMS REFERABLE TO BACK 724.9 OTHER UNSPECIFIED BACK DISORDERS 780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED 780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED 780.57 UNSPECIFIED SLEEP APNEA

780.58 SLEEP RELATED MOVEMENT DISORDER, UNSPECIFIED 786.09 RESPIRATORY ABNORMALITY OTHER 788.30 URINARY INCONTINENCE UNSPECIFIED 788.31 URGE INCONTINENCE 788.32 STRESS INCONTINENCE MALE 788.33 MIXED INCONTINENCE (MALE) (FEMALE) 935.2 FOREIGN BODY IN STOMACH MECHANICAL COMPLICATION OF OTHER IMPLANT AND INTERNAL DEVICE NOT ELSEWHERE 996.59 CLASSIFIED 997.49 OTHER DIGESTIVE SYSTEM COMPLICATIONS COMPLICATIONS AFFECTING OTHER SPECIFIED BODY SYSTEMS NOT ELSEWHERE 997.91 CLASSIFIED HYPERTENSION 998.31 DISRUPTION OF INTERNAL OPERATION (SURGICAL) WOUND 998.59 OTHER POSTOPERATIVE INFECTION 998.6 PERSISTENT POSTOPERATIVE FISTULA NOT ELSEWHERE CLASSIFIED Group 4 Paragraph: ICD-9-Codes that support medical necessity for CPT code 43999 when used to report gastric restrictive adjustment Group 4 Codes: V53.51 FITTING AND ADJUSTMENT OF GASTRIC LAP BAND ICD-9 Codes that DO NOT Support Medical Necessity N/A

General Information Associated Information Documentations Requirements All Claims Submitted fro Bariatric Surgery 1. Claims submitted for bariatric surgical procedures must contain three (primary, secondary and third) ICD- 9-CM codes as indicated below: The primary ICD-9-CM code 278.01 for morbid obesity (278.01) A secondary ICD-9-CM code describing a BMI > 35 V85.35; V85.36; V85.37; V85.38; V85.39; V85.41-V85.45 A third ICD-9-CM code from the list in this LCD describing co morbid condition 2. Documentation in the patient s medical record must contain a history and physical pertinent to the indications within this LCD. The medical record must clearly delineate the associated organic disease requiring surgical treatment of obesity. Documentation for Gastric Band Adjustment 1. Claims for an adjustment of a gastric restrictive device should be reported using CPT code 43999 with the statement "Adjustment of gastric restrictive device. ICD-9-CM code V53.51 should be used to report adjustment of a gastric restrictive device. 2. An adjustment of the gastric band (CPT code 43999) or an E&M service is not payable within the global period of the surgery when these services are performed by the same physician who performed the surgery. Utilization Guidelines 1. An E&M and the adjustment of a gastric band (CPT code 43999) will only be allowed on the same day if there was a significantly separate service provided. The modifier -25 should be appended to the E&M code to indicate the E&M service was a significantly separate service. Sources of Information and Basis for Decision Buchwald H, Avidor Y, Baunwald E, et al (2004). Bariatric surgery: A systematic review and metaanalysis. Journal of the American Medical Association; 292:1724-37. CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: Part 1, 40.5 Treatment of Obesity CMS Publication 100-03, Medicare National Coverage Determinations, Chapter 1: Part 2, 100.1 Bariatric Surgery for Treatment of Morbid Obesity CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 32, 150: Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2) June 27, 2012 DeMaria EJ, Pate V, Warthen M, Winegar DA. (2010). Baseline data from American Society for Betabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the bariatric outcomes longitudinal database. Surg Obes Relat Dis; 6:347-55. 19 Erickson P. Evaluation of a population-based measure of quality of life: the Health and Activity Limitation Index (HALex). Quality of Life Research 1998;7:101-14.

Finks JF, English WJ, Carlin AM, et al. (2012) Predicting risk for venous thromboembolism with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative. Ann Surg; 255:1100-4. Helmiö M, Victorzon M, Ovaska J, et al. (2012, April 5) SLEEVEPASS: A randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results. Surgical Endoscopy Himpens J, Dapri G, Cadiere GB. (2006) A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obesity Surgery 16:1450-6. Himpens, Jacques, et al. Long-term Results of Laparoscopic Sleeve Gastrectomy for Obesity, Annals of Surgery 2010; 252(2): 319-24. Hutter M, Schirmer B, Jones D, et al. (2011). First report from the American College of Surgeons Bariatric Surgery Center Network: Laparoscopic sleeve gastrectomy has morbidity and effectivenessbetween the band and the bypass. Annals of Surgery; 254:410-22. Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. (2008) Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-yy levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg;247:401-7. Kehagias I, Karamanakos S, Argentou M, Kalfarentzos F. (2011) Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI<50 kg/m2. Obesity Surgery; 21:1650-6. Lee W, Chong K, Ser K, et al. (2011) Gastric bypass vs sleeve gastrectomy for type 2 diabetes mellitus: a randomized controlled trial. Archives of Surgery; 146:143-8.18 Leonetti F, Capoccia D, Coccia F, et al. (2012) Obesity, Type 2 Diabetes Mellitus, and Other Comorbidities: A prospective cohort study of laparoscopic sleeve gastrectomy vs medical treatment. Archives of Surgery Leyba Luis Jose, et al. (2011) Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity: A prospective study of 117 patients. Obesity Surgery; 21:212-216. Peterli R, Wölnerhanssen B, Peters T, et al. (2009) Improvement in glucose metabolism after bariatricsurgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial. Annals of Surgery ;250:234-41. Peterli R, Steinert R, Woelnerhanssen B, et al. (2012) Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: A randomized, prospective trial.obesity Surgery ;22:740-8. Pories W, Swanson M, MacDonald K, et al. (1995) Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Annals of Surgery; 222:339-50. Regan JP, Inabnet WB, Gagner M, Pomp A., (2003) Early experience with two-stage laparoscopic Rouxen-Y gastric bypass as an alternative in the super-super obese patient. Obesity Surgery ;13:861-4. Rosenthal RJ, International Sleeve Gastrectomy Expert P, Diaz AA, et al. (2012) International Sleeve Gastrectomy Expert Panel Consensus Statement: Best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis ; 8:8-19. Schauer P, Kashyap S, Wolski K, et al. (2012) Bariatric surgery versus intensive medical therapy in obese

patients with diabetes. New England Journal of Medicine Schauer P, Burguera B, Ikramuddin S, et al. (2003) Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Annals of Surgery; 238:467-84. Weiner S, Sauerland S, Fein M, Blanco R, Pomhoff I, Weiner R. (2005) The bariatric quality of life (BQL) index: A measure of well-being in obesity surgery patients. Obesity Surgery; 15:538-45. White MA, Masheb RM, Burke-Martindale C, Rothschild B, Grilo CM. (2007) Accuracy of self-reported weight among bariatric surgery candidates: the influence of race and weight cycling. Obesity (Silver Spring) Woelnerhanssen B, Peterli R, Steinert R, Peters T, Borbély Y, Beglinge C. (2011) Effects of postbariatric surgery weight loss on adipokines and metabolic parameters: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy a prospective randomized trial. Surgery for Obesity and Related Diseases; 7:561-8. Revision History Information Please note: The Revision History information included in this LCD prior to 1/24/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 1/24/2013 will display as a row in the Revision History section of the LCD and numbering will begin with "R2". Revision History Date Revision History Number Revision History Explanation Reason(s) for Change 09/07/2013 R2 The WPS Carrier Contract Numbers 00951(WI), 00952(IL), and Change in Assigned 00954(MN) were removed from this LCD. Effective 09/07/2013, States or Affiliated the Jurisdiction 6 Part B MAC contractor for Illinois, Wisconsin, Contract Numbers and Minnesota is National Government Services (NGS). 03/01/2013 R1 03/01/2013: Corrected to include as payable co-morbid diagnoses inadvertently omitted ICD-9-CM codes 403.01, 718.08 and 997.49. Effective 02/15/2013 (one). Revisions Due To ICD-9-CM Code Changes 10/22/2012: In accordance with Section 911 of the Medicare Modernization Act of 2003 and CMS Change Request 8059, contractor numbers in this LCD policy were updated due to the transition from WPS Fiscal Intermediary Contract Number 52280 to WPS Part A MAC Contractor Number 05901. No other

changes were made to this LCD policy. Associated Documents Attachments Billing & Coding Guidelines 030113 opens in new window (PDF - 172 KB ) Related Local Coverage Documents N/A Related National Coverage Documents N/A Public Version(s) Updated on 08/26/2013 with effective dates 09/07/2013 - N/A Updated on 02/21/2013 with effective dates 03/01/2013-09/06/2013 Updated on 12/19/2012 with effective dates 02/15/2013 - N/A Keywords N/A Read the LCD Disclaimer opens in new window

Billing and Coding Guidelines; Bariatric Surgery for Morbid Obesity WPS Number: GSURG-042 Effective Date 02/15/2013 Revision Date 03/01/2013 Ending Effective Date AMA CPT Copyright Statement CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association Abstract: This billing and coding document is to be used with the LCD for Bariatric Surgery for Morbid Obesity. An excerpt for NCD 40.5, along with a copy of NCD 100.1, as well as other CMS provisions, is included in this document to assist and assure correct coverage for the bariatric surgical procedures. Excerpt from Medicare National Coverage Determinations Manual (NCD) Pub. 100-3, Chapter 1, Part 1, 40.5 - Treatment of Obesity A. General Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Non-surgical services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI >35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. B. Nationally Covered Indications Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI >35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. See 100.1. C. Nationally Noncovered Indications 1. Treatments for obesity alone remain non-covered. 2. Supplemented fasting is not covered under the Medicare program as a general treatment for obesity (Refer to NCD 40.5 for additional information).

Copy of Medicare National Coverage Determinations Manual (NCD) Pub. 100-3, Chapter 1, Part 2, 100.1 Indications: A. General Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of procedures. The following are descriptions of bariatric surgery procedures: 1. Roux-en-Y Gastric Bypass (RYGBP) The RYGBP achieves weight loss by gastric restriction and malabsorption. Reduction of the stomach to a small gastric pouch (30 cc) results in feelings of satiety following even small meals. This small pouch is connected to a segment of the jejunum, bypassing the duodenum and very proximal small intestine, thereby reducing absorption. RYGBP procedures can be open or laparoscopic. 2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) BPD achieves weight loss by gastric restriction and malabsorption. The stomach is partially resected, but the remaining capacity is generous compared to that achieved with RYGBP. As such, patients eat relatively normal-sized meals and do not need to restrict intake radically, since the most proximal areas of the small intestine (i.e., the duodenum and jejunum) are bypassed, and substantial malabsorption occurs. The partial BPD with duodenal switch is a variant of the BPD procedure. It involves resection of the greater curvature of the stomach, preservation of the pyloric sphincter, and transection of the duodenum above the ampulla of Vater with a duodeno-ileal anastamosis and a lower ileo-ileal anastamosis. BPD/DS procedures can be open or laparoscopic. 3. Adjustable Gastric Banding (AGB) AGB achieves weight loss by gastric restriction only. A band creating a gastric pouch with a capacity of approximately 15 to 30 cc's encircles the uppermost portion of the stomach. The band is an inflatable doughnut-shaped balloon, the diameter of which can be adjusted in the clinic by adding or removing saline via a port that is positioned beneath the skin. The bands are adjustable, allowing the size of the gastric outlet to be modified as needed, depending on the rate of a patient's weight loss. AGB procedures are laparoscopic only. 4. Sleeve Gastrectomy Sleeve gastrectomy is a 70%-80% greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume. In the past, sleeve gastrectomy was the first step in a two-stage procedure when performing RYGBP, but more recently has been offered as a stand-alone surgery. Sleeve gastrectomy procedures can be open or laparoscopic. 5. Vertical Gastric Banding (VGB)

VBG achieves weight loss by gastric restriction only. The upper part of the stomach is stapled, creating a narrow gastric inlet or pouch that remains connected with the remainder of the stomach. In addition, a non-adjustable band is placed around this new inlet in an attempt to prevent future enlargement of the stoma (opening). As a result, patients experience a sense of fullness after eating small meals. Weight loss from this procedure results entirely from eating less. VGB procedures are essentially no longer performed. B. Nationally Covered Indications Effective for services performed on and after February 21, 2006. Open and laparoscopic Rouxen-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. These 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 (program standards and requirements in effect on February 15, 2006). Effective for services performed on and after February 12, 2009, the Centers for Medicare & Medicaid Services (CMS) determines that Type 2 diabetes mellitus is a co-morbidity for purposes of this NCD. A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site and published in the Federal Register. C. Nationally Non-Covered Indications The following bariatric surgery procedures are non-covered for all Medicare beneficiaries: Open adjustable gastric banding; Open sleeve gastrectomy; and, Laparoscopic sleeve gastrectomy (prior to June 27, 2012) Open and laparoscopic vertical banded gastroplasty. The two previous non-coverage determinations remain unchanged - Gastric Balloon (Section 100.11) and Intestinal Bypass (Section 100.8). D. Other Effective for services performed on and after June 27, 2012, Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of standalone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions a.-c. are satisfied. a. The beneficiary has a body-mass index (BMI) 35 kg/m2 b. The beneficiary has at least one co-morbidity related to obesity, and, c. The beneficiary has been previously unsuccessful with medical treatment for obesity. CMS Original Effective Date: 02/21/2006

Excerpts from Medicare Claims Processing Manual, 100-04, Chapter 32 150 - Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity Coding Information Instructions for claims submitted to the carrier or Part B MAC: For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric surgery; 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components). 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less). 43645 Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847.) 43845 Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch). 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.) 43847 With small intestine reconstruction to limit absorption. 1. Claims for an adjustment of a gastric restrictive device should be reported using CPT code 43999 with the statement "Adjustment of gastric restrictive device" in item 19 of the CMS 1500 claim form or electronic equivalent. ICD-9-CM code V53.51 should be used to report adjustment of a gastric restrictive device. For additional information on adjustment of gastric restrictive devices see Documentation Requirements found in the LCD. Noncovered HCPCS Procedure Codes For services on or after February 21, 2006, the following HCPCS procedure codes are noncovered for bariatric surgery: 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty. 43999 used to bill for; Laparoscopic vertical banded gastroplasty Open sleeve gastrectomy Laparoscopic sleeve gastrectomy Open adjustable gastric banding ICD-9 Procedure Codes for Bariatric Surgery (FIs only) B. Covered ICD-9 Procedure Codes For services on or after February 21, 2006, the following ICD-9 procedure codes are covered for bariatric surgery: 44.38 Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or 44.39 Other gastroenterostomy (open Roux-en-Y), or

44.95 Laparoscopic gastric restrictive procedure (laparoscopic adjustable gastric band and port insertion), or to describe either laparoscopic or open BPD with DS, all three following codes must be on the claim: 43.89 Other partial gastrectomy, and 45.51 Isolation of segment of small intestine, and 45.91 Small to small intestinal anastomosis. NOTE: There is no distinction between open and laparoscopic BPD with DS for the inpatient setting. For either approach, all three codes must appear on the claim to be covered. *Effective June 27, 2012, the following ICD-9 procedure code is covered for bariatric surgery: 43.82 Laparoscopic sleeve gastrectomy covered at contractor s discretion ICD-9 Procedure Codes for Bariatric Surgery (FIs only) C. Non-covered ICD-9 Procedure Codes For services on or after February 21, 2006, the following ICD-9 procedure codes are noncovered for bariatric surgery: 44.68 Laparoscopic gastroplasty (vertical banded gastroplasty). 44.69 Other. Inversion of gastric diverticulum. Repair of stomach NOS. 43.89 Other partial gastrectomy. NOTE: 44.68 is non-covered when used to bill for open adjustable gastric banding and laparoscopic vertical banded gastroplasty. 44.69 is non-covered when used to bill for open vertical banded gastroplasty. 43.89 is non-covered when used to bill for open and laparoscopic sleeve gastrectomy. Excerpt from 100-04, chapter 32, 150.8 - Fiscal Intermediary Billing Requirements The FI will pay for bariatric surgery only when the services are submitted on the following type of bill (TOB): 11X. Type of facility and setting determines the basis of payment: For services performed in IHS inpatient hospitals, TOB 11X under IPPS payment is based on the DRG. For services performed in inpatient hospitals, TOB 11X under IPPS payment is based on the DRG. For services performed in IHS critical access hospitals, TOB 11X, payment is based on 101% facility specific per diem rate. Instructions for Carriers, Fis, MAC A and MAC B ICD-9 Diagnosis Codes for Bariatric Surgery For services on or after February 21, 2006, the following ICD-9 diagnosis code is covered for bariatric surgery if certain other conditions are met: 278.01 - Morbid obesity; severe obesity. Excerpt from 150.5 ICD-9 Diagnosis Codes for BMI 35 The following ICD-9 diagnosis codes identify BMI 35: V85.35 - Body Mass Index 35.0-35.9, adult V85.36 - Body Mass Index 36.0-36.9, adult V85.37 - Body Mass Index 37.0-37.9, adult

V85.38 - Body Mass Index 38.0-38.9, adult V85.39 - Body Mass Index 39.0-39.9, adult V85.41 - Body Mass Index 40.0-44.9, adult V85.42 - Body Mass Index 45.0-49.9, adult V85.43 - Body Mass Index 50.0-59.9, adult V85.44 - Body Mass Index 60.0-69.9, adult V85.45 - Body Mass Index 70.0 and over, adult The medical record of the patient must have documented all of the following; 1. A diagnosis of 278.01 (morbid obesity. 2. A body mass index (BMI) > than 35 as documented with one of the following ICD-9-CM codes; a. V85.35; V85.36; V85.37; V85.38; V85.39; *V85.41-V85.45 3. At least one co-morbidity related to obesity that is listed in the ICD-9 secondary diagnosis section below. WPS Medicare will process covered bariatric surgery claims as follows: 1. Identify bariatric surgery claims. 2. Identify inpatient bariatric surgery claims by the presence of ICD-9-CM diagnosis code 278.01 for morbid obesity and one of the covered ICD-9-CM procedure codes listed in 150.3. 3. Identify practitioner and institutional outpatient bariatric surgery claims by the presence of ICD-9-CM diagnosis code 278.01 for morbid obesity and one of the covered HCPCS procedure codes listed in 150.2. 4. Perform facility certification validation for all bariatric surgery claims on a pre-pay basis. 5. A list of approved facilities may be found on the CMW web site. 6. WPS Medicare may review bariatric surgery claims data and determine whether a pre- or post-pay sample of bariatric surgery claims need further review to assure that the beneficiary has a BMI >35 (V85.35 -V85.41-V85.45) and at least one co morbidity related to obesity. 7. The carrier/fi/a/b MAC medical director may define the appropriate method for addressing the obesity-related co morbid requirement. NOTE: If ICD-9-CM diagnosis code 278.01 and one of the covered ICD-9-CM procedure codes listed in 150.3 or HCPCS procedure codes listed in 150.2 are not present, the claim is not for bariatric surgery and should be processed under normal procedures. 1. Do not report 43645 (laparoscopy, with gastric bypass and small intestine reconstruction to limit absorption) in conjunction with 49320 (surgical laparoscopy) or 43847 (gastric bypass for morbid obesity). 2. For greater than 150 cm. use 43847 3. For laparoscopic procedure use 43644

Reasons for Denial WPS Medicare will process non-covered outpatient bariatric surgery claims according to the conditions outlined below: 1. CPT procedure code 43842 will be denied when used for: open vertical banded gastroplasty. 2. COT code 43999 (an NOC code) will be denied when used to bill for; Laparoscopic vertical banded gastroplasty Open sleeve gastrectomy Laparoscopic sleeve gastrectomy Open adjustable gastric banding Revision History/Explanation 03/01/2015: Deleted under section C. Nationally Non-Covered Indications statement no longer found in the NCD that said; Effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a BMI <35 are not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, and therefore are not covered. Italicized font - represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process at www.cms.gov