Medicare Coverage for Bariatric Surgery: Do You Know These BMI Guidelines?

September 1, 2009

Question: I heard that Medicare made some changes about diabetic patients’ eligibility for bariatric surgery. Do we have to pay more attention to the patient’s BMI?

Answer: A few months ago, Medicare did implement some new regulations for bariatric procedures for diabetic patients.

The rule: If your physicians perform bariatric surgery procedures on diabetic patients you need to take note of the patient’s body mass index (BMI) ” it could be your magic number in determining the patient’s eligibility for Medicare payment, according to MLN Matters article MM6419, which had an implementation date of May 18.

Effective for any services performed on Feb. 12 or thereafter, the following three procedures are not covered for patients with type II diabetes and a BMI under 35:

• Open and laparoscopic Roux-en-Y gastric bypass (43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Rouxen-Y gastroenterostomy and 43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less])

• Laparoscopic adjustable gastric banding (43770,Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device [e.g.,gastric band and subcutaneous port components] and

43773, … removal and replacement of adjustable gastric restrictive device component only)

• Open and laparoscopic biliopancreatic diversion with duodenal switch (43845-43847, Gastric restrictive procedure with partial gastrectomy … and 43645, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption).

The upside: CMS will cover these procedures in patients who have type II diabetes and a BMI of 35 orhigher.

AUDIO: Get your bariatric surgery claims paid. Diagnosis coding tips, bariatric anatomy 101, pre-authorization moves & much more.

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