Part B Insider (Multispecialty) Coding Alert

Published on Thu Nov 03, 2005 PDF

Medicare considers expanding coverage for clinical trials

Your older obese patients may be out of luck if they're seeking gastric bypass surgeries.

The Centers for Medicare & Medicaid Services says it's considering ending coverage of gastric bypass surgeries for patients aged 65 and older. These procedures include open and laparoscopic roux-en-y gastric banding and laparoscopic adjustable gastric banding. But CMS says it may cover more procedures in the context of clinical trials.

Other gastric procedures, including open and laparoscopic vertical banded gastroplasty and open adjustable gastric banding, will be non-covered for all Medicare patients, CMS says.

You might think that ending coverage for older patients would end all Medicare coverage, but it's not true. Many of the Medicare beneficiaries who currently receive these surgeries are younger but disabled. CMS' decision is based on some recent studies, including a paper in the Journal of the American Medical Association that found death rates were two-to-three times higher among older patients undergoing bariatric surgery.

"It's a big mistake," says Mary Lou Walen, coding expert at the American Bariatric Surgery Association. Older patients can have more quality of life, including longer lives, and cost the system less money, if they undergo bariatric surgery, says Walen.

She recounts the story of one 70-year-old man who had bariatric surgery, and sent her a postcard two years later from inner Africa, where he was serving with the Peace Corps. "Instead of someone getting more and more debilitated," says Walen, "you've got a very productive member of society for a long-term period."

She says Medicare should focus on working with physicians and facilities to make sure patients are good candidates for the surgery and are well-prepared for the operation and its aftermath.

CMS is also proposing criteria for facilities performing bariatric surgery, including credentialing for surgeons and staff and consultant qualifications. And the agency is seeking comment on whether to impose specific volume criteria for facilities or surgeons.