UPDATE: Include Gastric Band Adjustments in E/M Service
The information below is no longer current: On Nov. 19, 2012 Medicare Part B Carrier Palmetto GBA issued an updated policy instructing coders to report 43999 Unlisted procedure, stomach for gastric band adjustments that occur outside the global period of gastric restrictive procedures. Palmetto now specifies:
“To submit a claim for adjustment of Gastric Restrictive Device:
- Only reimbursable in the office setting
- Submit CPT Code 43999 (Unlisted procedure, stomach)
- Narrative field put the words ‘adjustment of lap-band’
Imaging to locate the port would be included in the service of CPT code 43999.”
When billing for gastric band adjustments outside of the global period of 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty or 43659 Unlisted laparoscopy procedure, stomach for Medicare part B patients in California, Nevada, and Hawaii, you should report only a medically-necessary evaluation and management (E/M) service at the level of 99213 Office or other outpatient visit for the evaluation and management of an established patient…. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
Per instructions from Palmetto GBA, Medicare Part B carrier for Jurisdiction 1 (Calif., Nev. Hawaii.), “Prior to making an adjustment, Medicare expects a medically necessary evaluation and management service to be performed. The adjustment is included in the E/M service provided on the date of service for the E/M code billed. Ordinarily this would be at the level of CPT® code 99213.”
The number and frequency of adjustments to the band depends on individual considerations. Most patients have between five and eight adjustments within the first year after surgery. There is no specific HCPCS code that describes these adjustments. You should not report an unlisted procedure code for these adjustments, according to Palmetto, or the claim will be rejected for incorrect coding.