Revenue Cycle Insider

Question: I now work for a surgeon who performs bariatric surgeries, and many of our patients are Medicare beneficiaries. Are there any tips to make sure my claim is ready for Medicare?

AUDITCON Attendee

Answer: Consider making a template in a spreadsheet that you can use every time you’re preparing a claim for this procedure for Medicare — or any procedure for any payer.

You may be able to find specific coverage determination requirements from your respective Medicare Administrative Contractor (MAC). Here’s what the Centers for Medicare & Medicaid Services (CMS) says about bariatric surgery coverage.

“Although there are multiple areas of conservative care and criteria that need to be met for Medicare to pay for this particular service, we would probably want to set our spreadsheet up so that we can document yes or no, make comments, and so on, to show that we’ve performed this procedure in compliance with Medicare,” said Pam Warren, MHA, COC, CPC, AAPC Fellow, in her AAPC’s AUDITCON 2025 presentation “Tools for Auditing.”

When you’re setting up the template, Warren suggested using these categories, which Medicare requires for coverage:

• Body mass index (BMI)
• Comorbidity
• Documentation of conservative treatment
• Rule-out (R/O) metabolic obesity
• Documentation of patient’s knowledge/tools for weight loss
• Documentation of failed medically supervised structured dietary program
• Preoperative psychiatric evaluation and clearance
• Limitations as noted in chart

Instead of populating each category with the information to go on the claim, you can use the spreadsheet as a sort of checklist; or, you can go ahead and add as much information as makes sense (and remains compliant). And if you ever want to audit your documentation and claims, you can use the various spreadsheet functions and formulae to organize, sort, and evaluate the data you’ve input.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC