New Technology Advances Bariatric Surgery
For more precise coding, understand underlying causes, anatomy, and new treatment options for obesity.
By Laurette Pitman, RN, CPC-H, CGIC, CCS
Obesity has become a public health concern in the United States. In 2012, 26.2 percent of Americans were considered to be obese; of this population, 4 percent were considered to be morbidly obese.
Body mass index (BMI) is the primary measurement used to classify obese patients. In 1991, the National Institutes of Health provided the following definitions:
|Category||Body Mass Index (kg/m2)||Over Ideal Body Weight (%)|
|Overweight||25.0 – 29.9|
|Obesity (class 1)||30 – 34.9||>20%|
|Severe obesity (class 2)||35 – 39.9||>100%|
|Severe obesity (class 3)||40 – 49.9|
Factors, Associated Conditions, and Non-surgical Treatment
Simply put, obesity occurs when a person takes in more calories than he or she burns through exercise and normal daily activities. The body stores the excess calories as fat. Additional factors that may contribute to the development of obesity include:
- Unhealthy diet and eating habits
- Lack of sleep
- Certain medications
- Medical problems (Prader-Willi syndrome, Cushing’s syndrome, polycystic ovary syndrome, hypothyroidism)
There are more than 30 co-morbid conditions associated with severe obesity. According to information from the Cleveland Clinic, the most common of these is insulin resistance and diabetes mellitus, which occur in 15-25 percent of obese patients. Other common obesity-related conditions include hypertension, heart disease, cancer, osteoarthritis of weight bearing joints, sleep apnea, respiratory problems, gastroesophageal reflux disease, depression, infertility, and urinary stress incontinence.
Obesity treatment may start with counseling on diet, exercise, and lifestyle modifications. In patients who fail to achieve weight loss goals through diet and exercise alone, or who have significant co-morbidities, pharmacologic therapy may be added.
Multiple drugs now on the market may be prescribed for appetite suppression. All have side effects. The choice of drug is usually dependent on the patient’s ability to tolerate those side effects. According to the Cleveland Clinic, the amount of weight loss achieved through pharmacologic therapy is generally modest (< 5 kg at one year).
In recent years, we have seen surgical options for morbid obesity become more common. Patients with a BMI >35 kg/m2 with obesity-related co-morbidities, and those with a BMI >40 kg/m2 with or without co-morbidities, are eligible for bariatric surgery. Other criteria for surgical candidacy include:
- • Acceptable operative risk
- • Documented failure of nonsurgical weight loss programs
- • Psychologically stable, with realistic expectations
- • Well-informed and motivated patient
- • Supportive family and social environment
- • Absence of active alcohol or substance abuse
- • Absence of uncontrolled psychotic or depressive disorder
The National Institutes of Health guidelines recommend bariatric surgery to be limited to patients 18-60 years old.
The most commonly performed bariatric procedures are the Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and the sleeve gastrectomy. All of these procedures have a CPT® Category I code available for assignment when these surgeries are performed. Because coverage guidelines for each procedure vary by payer, you must know these individual guidelines to bill appropriately and receive reimbursement.
Roux-en-Y Gastric Bypass
The Roux-en-Y gastric bypass combines a restrictive component and a limited proximal intestinal bypass, and is the most common bariatric procedure performed in the United States. This procedure can be performed by open or laparoscopic techniques, with the laparoscopic procedure resulting in a faster recovery and fewer complications.
A small, 15 to 30 mL gastric pouch is created to restrict food intake, and a Roux-en-Y anastomosis bypasses the duodenum and proximal jejunum. This procedure has been found to result in superior weight loss and co-morbidity resolution.
CPT® codes for this procedure are 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy and 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.
Adjustable Lap Band
The laparoscopic adjustable gastric band has been approved for use in the United States since 2001. A silicone band with an inflatable inner collar is placed around the upper portion of the stomach to create a small gastric pouch, and to restrict the gastric cardia. The band is connected to a port that is placed in the subcutaneous tissue of the abdominal wall. The inner diameter of the band can be adjusted by injecting saline through the port.
The Category I CPT® code for insertion of the lap band is 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components). Several codes are available for the removal, revision, and replacement of the device.
Laparoscopic Sleeve Gastrectomy
The laparoscopic sleeve gastrectomy has been in use as a bariatric procedure for approximately 10 years. This procedure involves a vertical resection and removal of the body and fundus of the stomach, which leaves a tubular gastric lumen from the gastroesophageal junction to the antrum. The pylorus is left intact and no device is implanted nor bypass performed.
This procedure is reported with 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy).
Vagus Nerve Blocks
Medical science is constantly searching for newer, better, and less invasive means of treating diseases such as obesity. One method being investigated is vagus nerve blocking therapy, which uses high frequency, small electrical pulses to block the transmission of the vagal nerve signals to the brain.
The vagus nerve is the longest cranial nerve, containing motor and sensory fibers, and has the widest distribution in the body. The gastric branches of the vagus nerve supply the stomach and play a significant role in food processing, and in signaling the feeling of fullness and prolonging the absence of hunger.
Studies have shown that patients who undergo surgical vagotomy commonly experience weight loss. In some cases, the effects were found to be temporary, as the body is usually able to compensate for the anatomical disruption by regulating to normal function. Consequently, a technique for intermittent blocking of the vagus nerve by laparoscopically implanted electrodes (which prevent the nervous system and digestive organs from compensating for changes in bodily functions) was developed for potential management of obesity.
The procedure involves a laparoscopic approach, where the physician makes three to five, 1 cm incisions to implant the electrodes. Through the smaller incisions, the physician inserts small electrodes around the vagus nerve near the distal esophagus. A neuroregulator is then placed under the skin, at a location selected by the physician in collaboration with the patient.
Two weeks after completion of the surgical procedure, the vagal blocking therapy is initiated in the physician’s office with programming of the neuroregulator. Patients may eat normal foods as part of a sensible diet with this device.
The potential benefit to the vagal nerve blocking system is that it does not alter the patient’s gastric anatomy and can be performed on an outpatient basis with regulation of the blocking system in the physician’s office, or with wireless communication technology.
This procedure/therapy is not approved in the United States. Clinical trials are now being performed by EnteroMedics® in the ReCharge Study as part of the U.S. Food and Drug Administration premarket approval process. The device developed by EnteroMedics® is called the Maestro® Rechargeable System.
Call on Category III for Vagal Nerve Blocking Systems
There are no CPT® Category I codes available for this new technology yet; however, CPT® does provide a set of temporary (Category III) codes for emerging technology, services, and procedures. If a Category III code is available for reporting a new procedure, it must be used rather than the Category I unlisted procedure code.
The Category III codes 0312T-0317T are to be used to report the laparoscopic vagus nerve blocking therapy for the treatment of morbid obesity (see the accompanying sidebar, “Category III Code Descriptions,” for the full descriptions). The services identified by these codes include:
- Laparoscopic implantation of the neurostimulator electrode array and pulse generator (0312T)
- Revision or replacement of the neurostimulator array with connection to existing generator (0313T)
- Removal of the neurostimulator electrode array and pulse generator together (0314T)
- Removal of the pulse generator independent of the electrode array (0315T)
- Replacement of the pulse generator (0316T)
- Electronic analysis of the pulse generator with reprogramming, if performed (0317T)
The Category III codes for the vagus nerve blocking procedure are scheduled to sunset in January 2018. If this procedure is performed after the archiving of the Category III codes without Category I codes assigned to replace them, it would be necessary to use appropriate unlisted procedure codes.
With the increasing incidence of obesity seen by medical practitioners, you can expect in the future to see other new technologies and treatments geared toward this and other associated co-morbid diseases. As coding professionals, you should be aware of all new Category III codes, as well as the coverage implications that are associated with any new treatments or procedures.
Laurette Pitman, RN, CPC-H, CGIC, CCS, is a senior outpatient consultant for SPi Healthcare. She has over 30 years’ experience in the healthcare field, including ED and OR nursing, coding, and DRG and APC auditing. Pitman is also an ICD-10-CM/PCS trainer and a member of the Lafayette, La., local chapter. For more information, please reference www.spihealthcare.com or email her at firstname.lastname@example.org.