Biliopancreatic diversion with DS - Newbie, please assist

[Kisalyn]

I'm looking at our WPS LCD for bariatric surgery and it lists all the covered CPTs.

One item I need clarification on is for the covered procedures of both open and lap BPD/DS. Does CPT 43845 apply to both open and lap? This CPT is listed in the book under "Other Procedures." Some of those procedures specifies whether they are open procedures, but none specify whether they are lap.

I don't think it's the unlisted code because the LCD specifically states that the unlisted is only covered for gastric band adjustments.

New to general surgery and would appreciate any help. Thanks!

 

[Kisalyn]

Is this an uncommon procedure? Any help?

 

[cynthiabrown]

yes, it is for open or lap....isn't that just against everything a coder is taught??? I struggled with this one too!

 

[Kisalyn]

Wow, that is interesting. I appreciate the response!

 

[Kisalyn]

Just wanted to update my thread. I emailed our MAC, WPS, and this is their response:

"Thank you for contacting Wisconsin Physicians Service (WPS) Medicare for assistance regarding Local Coverage Determination (LCD), “Bariatric Surgery for Morbid Obesity (L32904).” As you are probably aware, you can view a copy of the policy on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32904&ContrId=265

Please note I consulted with our Medical Policy staff regarding your inquiry. The response below is reflective of the response I received.

The biliopancreatic diversion with duodenal switch (BPD/DS) surgical procedure can be performed either as an open or laparoscopic procedure. However, the Current Procedural Terminology (CPT) code of 43845 is for the open procedure. Due to the fact, there is not a CPT code for the laparoscopic BPD/DS procedure; WPS Medicare suggests the surgeon bill using the unlisted surgical laparoscopy stomach CPT code of 43659. When billing unlisted CPT codes to Medicare, you should indicate on the claim that you have additional documentation to provide. Once we receive the claim, the WPS Medicare staff will evaluate the claim and request medical record documentation if necessary. Medical necessity will be determined at that time, taking into consideration information published in LCD L32904. If medical necessity is established, we will analogue pricing to that of the open procedure (CPT code 43845)."