Our radiology group informs all referring physicians that they need to set up a contract so that the surgeon pays our radiologist a certain fee for each of their patients we inject saline into the lap band, or adjust the lap band, or repair the lap band (including OR interventions like gastric and/or esophageal dilitation). The fees differ based on the type of procedure we perform however if the surgeon refuses to agree to such contract we collect the payment from the patient including a signed waiver. The only scenario this does not apply to is life-threatening or emergency cases that require intervention. For the emergency-type procedures we have had to bill some with a 25 modifier just for payment while other commercial carriers just flat out refuse! I, like most of you guys, had to play the billing game with each ins to see what they would finally pay.
When I first contacted Medicare about the most appropriate way to bill they referred me to the article below.
Adjustment of Gastric Band after Bariatric Surgery
Bariatric Surgery falls under a Medicare National Coverage Determination (NCD 100.1, ref. 1.) All bariatric surgeries which are payable by Medicare must be performed in an approved facility. Gastric banding (e.g. “Lap Band”) is one of the covered types of bariatric surgeries. There are a series of specific CPT codes for gastric band placement, revision, replacement, port removal, and other related surgeries (CPT codes 43770-43774 and 43886-43888). Specific local coding guidance for bariatric surgery is provided in NHIC's Local Coverage Determination (LCD) for Bariatric Surgery (ref. 2). This guidance provides details of coverage which are not available in the NCD.
Gastric Band Adjustment
There is no specific code for an adjustment of the gastric band. Note that within 90 days of the original surgery, adjustments fall within the (bundled) global period for post-operative management. There is no separate new payment for staged adjustments that fall within the surgical global period.
Medically necessary adjustments outside the 90 day global period may be coded with CPT code 43999, unlisted procedure, stomach. State "Gastric band adjustment” in the comment field for this unlisted code. Do not use CPT code 90779, because this code is specifically for “intra-arterial or intravenous” injections.
Fluoroscopic guidance, if used, may be coded as CPT code 76000 {Fluoroscopy (separate procedure), up to 1 hour physician time}.
Evaluation and Management (E/M) associated with Gastric Band Adjustment (43999)
An E/M service may be charged (using modifier 25) if it is separately identifiable from the actual adjustment. For example, an appropriate evaluation of the patient's new complaint(s) or management issues, interval history, physical examination, medical decision-making, etc, is payable along with the adjustment procedure itself. If the patient had such a visit and decision-making previously, and is simply returning for the procedure, a separate E/M service should not be charged.
Editing of Gastric Band Adjustment (43999)
Claims for gastric band adjustment are not edited as stringently as the primary bariatric surgery. For example, the site of service does not have to be a bariatric-approved hospital and the ICD-9-CM code(s) may be different than the original surgery (for example, the patient in question may no longer have symptomatic diabetes as he did before the original surgery one year earlier.) Gastric band adjustment is not part of either the NCD or LCD on bariatric surgery, and therefore reasonable community standards apply for medically necessary adjustments.
References
Ref. 1 Internet-Only Manual, Pub. 100-03, NCD 100.1. See also Pub. 100-04, Chapter 32, Section 150.
Posted 8/16/2007; Removed CA reference 8/29/2008
Anita Elder, CIRCC, CPC, RCC
radcoder4msn@yahoo.com