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Laparoscopic Sleeve Gastrectomy: Change Is Good

November 29, 2012:

Brigid T. Caffrey, BA, BS, CCS, Manager, Clinical/Technical Editors

Laparoscopic sleeve gastrectomy may now be covered as a stand-alone procedure for treating comorbidities related to obesity. Details of the change were released November 9, 2012, in Centers for Medicare and Medicaid Services (CMS) Transmittal 2590 to Pub. 100-04, the Medicare Claims Processing manual, and Transmittal 148 to Pub. 100-03, the Medicare National Coverage Determinations manual.

Effective June 27, 2012, Medicare administrative contractors (MAC) may decide coverage for ICD-9-CM volume 3 code 43.82 Laparoscopic vertical (sleeve) gastrectomy, when performed on a patient with a body-mass index (BMI) greater than or equal to 35 kg/m2 who has at least one comorbidity related to obesity, and when there is documentation of previously failed medical treatment for obesity.

Sleeve gastrectomy is the partial excision of the greater curvature of the stomach, after which the remnant looks like a tube or sleeve. It can be performed as a stand-alone procedure to reduce stomach volume. Medicare approves 564 hospitals as bariatric facilities.

Laparoscopic sleeve gastrectomy is reported in ICD-10-PCS with code 0DB64Z3, which maps to ICD-9-CM code 43.82. In ICD-9-CM, the principal diagnosis of morbid obesity is classified to 278.01 (code E66.01 in ICD-10-CM). If documentation specifies the diagnosis of morbid obesity with hypoventilation syndrome for the gastrectomy encounter, add code 278.03 (a complication/comorbid condition) in ICD-9-CM. In ICD-10-CM, both conditions are classified to combination code E66.2. BMI scores of 35 kg/m2 or higher are classified to codes V85.35 through V85.45 in ICD-9-CM, or codes Z68.35 through Z68.45 in ICD-10-CM. The MAC will determine what qualifies as obesity-related comorbid conditions. Laparoscopic sleeve gastrectomy groups to MDC 10 and MS-DRG 619, 620, or 621, which are based on the presence or absence of CC/MCC conditions.

CPT code 43775 Laparoscopy, surgical, gastric restrictive procedure, longitudinal gastrectomy (i.e., sleeve gastrectomy) describes an inpatient-only procedure that is excluded from ASC payment. The procedure is therefore not covered when performed in the outpatient setting.


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