Shed the Extra Coding in Bariatric Surgery

By Koressa Gregory, CPC<

Obesity is a serious medical condition affecting more than 60 percent of the U.S. population. It is the second leading cause of premature death in the United States., according to the Journal of the American Medical Association (JAMA), and is second to smoking; with 400,000 preventable deaths annually. Approximately $238 billion represent 6 percent of U.S. health care expenditures per year. Morbid obesity is defined as greater than 75 to 100 pounds overweight, or a body mass index (BMI) of greater-than or equal-to 40. It is a life-long progressive, life-threatening, genetically-related, and costly disease with multiple co-morbidities of:
  • Diabetes
  • Osteoarthritis and gout
  • Hypertension
  • Infertility and menstrual problems
  • Lipid disorders
  • Obstetric complications
  • Heart disease
  • Low back pain
  • Asthma
  • Deep vein thrombosis and thromboembolism
  • Sleep apnea
  • Depression
  • Gall stones
  • Immobility
  • Non-alcoholic steatohepatitis (NASH)
  • Venous/stasis ulcers
  • Urinary incontinence
  • Skin infections
  • Gastro esophageal reflux disease (GERD)
  • Intertrigo

There are many options to correct morbid obesity and prompt rapid weight loss. Bariatric surgery is one of these weight loss options. There are several different bariatric procedures and many codes associated with the variety of procedures. Weigh your coding options depending on the procedures.

Lap-Band® (43770)

After performing a series of small incisions, the surgeon uses a small camera through a laparoscope to visualize placement of the Lap-Band® placed through one of the small incisions. The Lap-Band® is a silicone belt placed around the top of the stomach and secured in place with sutures. It is adjustable, connected to a port used to tighten and loosen the band. The port is placed underneath the skin at the top part of the abdomen. Surgery takes about an hour, and an overnight stay in the hospital may be required. Use 43700 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) for this procedure.

Saline is injected into the port to inflate the band, making the passage to the lower part of the stomach smaller, which restricts food intake. If the band is too tight, fluid can be removed in the physician’s office.

Gastric Bypass Surgery

The gastric bypass procedure is a complex procedure performed under general anesthesia. Time in surgery is approximately one to four hours, followed by a one- to seven-day stay in the hospital. Currently, two techniques are available for gastric bypass: the Roux-en-Y-gastric bypass (traditional and laparoscopic) and the biliopancreatic diversion bypass.

In both techniques, a small stomach pouch is created, to decrease food intake by stapling a portion of the stomach. A Y-shaped portion of the small intestine is attached to the stomach pouch so food can bypass the duodenum and extend to the initial portion of the jejunum. The bypasses of the small intestine are formed to decrease the absorption of food nutrients. These techniques significantly restrict food intake and reduce hunger to promote weight loss. The majority of the weight loss is within one year and is usually completed by the end of the second year.

The traditional Roux-en-Y-gastric bypass is performed through open surgery with one long incision. The Roux-en-Y gastric bypass can also be performed laparoscopically. The laparoscopic Roux-en-Y-gastric bypass uses multiple smaller incisions rather than one long incision. A laparoscopic tool is inserted, offering a visual guide to the inside of the abdomen during the procedure. The laparoscopic Roux-en-Y creates less scarring and requires less recovery time than the traditional Roux-en-Y-gastric bypass. The laparoscopic approach is fairly new, so long-term results have not been fully evaluated.

The Roux-en-Y bypass is more common and considered less complicated than the biliopancreatic diversion bypass, as the Roux-en-Y bypass does not remove portions of the stomach.

For traditional Roux-en-Y gastric bypass use codes 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy and 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption. If the procedure is laparoscopic, use code 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) or 43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption.

Biliopancreatic Diversion Bypass

The biliopancreatic diversion bypass is performed through open surgery with one long incision. In the biliopancreatic diversion, portions of the stomach are removed and the bypass is attached to the distal ilium. This procedure is not widely used, because there is a higher risk of nutritional deficiencies. CPT® code 43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) is appropriate when billing for this procedure.

Minimally Invasive Technique: da Vinci® Robotics

In some surgeries, robotic assistance is employed. A surgeon sits at a special station and controls the da Vinci® robot remotely. Unlike surgeons, the robot’s arms have wrists with eight degrees of freedom and much smaller, hand-like devices, creating smaller incisions precisely in the patient’s body. The robot allows surgeons to see the organs in 3-D. Some surgeons feel that this reduces risk, trims total operation time, and shortens patient recuperation. In many cases, use of the da Vinci® arm is considered incidental. However, it can be reported using HCPCS Level II code S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure).

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