Wiki Bariatric coding HELP!!

[amy.brown@ttuhSc.edu]

Specifically 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).

The descriptor is causing some confusion and differences in opinion because it doesn't specifically say open or laparoscopic approach. Can 43845 be used for both approaches? Can anyone clarify or provide resources to find this answer? This has been a 3+ years quest!!!!!!

 

[OpenClaims]

Here is a CMS link to bariatric codes - Article - Billing and Coding: Bariatric Surgery Coverage (A53026)

If you scroll to the bottom to the CPT/HCPCS codes, you'll notice that some codes list laparoscopic in their description and the other do not. That makes me think that unless is says laparoscopic, it's open.

 

[OpenClaims]

The descriptor is causing some confusion and differences in opinion because it doesn't specifically say open or laparoscopic approach. Can 43845 be used for both approaches? Can anyone clarify or provide resources to find this answer? This has been a 3+ years quest!!!!!!

Hello, to answer your first question, No you cannot use codes interchangeably for open and lap. If the description of the code does not state "laparoscopic" then it is an Open procedure. So if you come across this issue where the procedure was performed laparoscopically and there is only an open code available you would resort to your unlisted laparoscopic codes.
So for this category since you are working in the stomach you would use the unlisted code 43659- (your EMR system will not have a price on this code because it is an unlisted code). So then you would find a comparable code, which is your open code 43845. You can price your unlisted lap code 43659 to the price of 43845 (but you are NOT entering the CPT code on the claim, only the price). Then in your box 19 of your claim form you would tell the insurance company what code are you comparing this unlisted code to. It will look something like this (box 19)- 43845- lap gastric restrictive, with partial gastrectomy, duodenileostomy and ileoileostomy. (you can only fit so much in the box, but the code you are referencing as your comparable code tells the insurance that this is the procedure you performed but it was done as a lap procedure. You will most likely have to send over documentation for the insurance company to verify that this procedure was performed laparoscopically. So if you get a denial, do not get discouraged just send over some documentation or appeal with documentation to prove the lap procedure.

For example:
Claim line 1- 43659- E66.01, Z68.43= $3500
(what ever price you have for your open procedure 43845 in your system, or if your office has a policy of how much should be billed for this example you would use that pricing)

Box 19 on claim form: 43845- lap gastric restrictive, with partial gastrectomy, duodenileostomy and ileoileostomy