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Wiki ??? for Bariatric coders

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buppkl

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What do you code in the case where the surgeon plans to do a laparoscopic biliopancreatic diversion with duodenal switch in two stages? some insurance companies do not cover the sleeve gastrectomy, which is the first part of this procedure. Also, I don't know of the BPD/DS to have a code if done laparoscopically. Need help with this scenario. What if the procedure is planned for being done at one session, laparoscopically and then the doc cannot complete it? Would you use just the sleeve code and not get paid or use the BPD/DS and add a modifier?
 
I do bariatric billing/coding, but we've only billed for a couple sleeve gastrectomies since they are still considered expiremental by most insurance carriers, but my opinion is bill sleeve gastrectomy if that's what is performed. (43775 for laparoscopic) Then if the BPD is performed later use modifier 58.
 
bariatric 43775 surgical assist

Some of the CT payors (Oxford) are allowing the gastric sleeve but not allowing the assistant surgeon. I find this odd since the RVUs are 37.81. According to the 2011 National Fee Schedule RVU File, there are no global days and assist surg is "N". If any one has had a similar situation, let me know how you handled it.
 
43775 Assistant Surgeon Facts

We have been fighting all year appealing adverse determinations for an assist on 43775. After being told by United Healthcare that they follow CMS guidelines and in 2011 CMS changed the fee schedule status code to a 9 (concept does not apply) instead of a 2 (assistant at surgery can be paid) as it was in 2010.

United Healthcare thinks the status indicator "9" means "not allowed" because the status code for the CPT is "N" which means it is not a covered code by Medicare for any provider.

We contacted NCCI and requested clarification of this and the response from NCCI is that United Healthcare has misinterpreted the information. If there are other payers out there denying the assistant surgeon, it is probably the same issue.

We have also written a letter to ASMBS and the response is: an assistant surgeon would be necessary on a Gastric Sleeve due to the complexity.

Yesterday, we met with the Regional United Healthcare Medical Director about this issue and gave him all of our documentation. He made the statement that "this is the first time anyone has said anything about this to us."

He said sometimes they do misinterpret information but could not guarnatee that all of the denials for the assistant surgeon's be reconsidered retroactively. To change corporate policy at the National level is difficult.

I know this is not true because we had a similar meeting in 2005 with the UHC Medical Director regarding the Lap Band. All of our claims were retroactively reconsidered and paid.

The surgeons are deflated and feel defeated since we find out NO ONE has complained about this.

This is my plea to all Bariatric coders: We need to stand together on this and fight for what is correct coding! You all know the Sleeve would require an assistant, just look at the RVU's. Ask your surgeon.

If carriers are going to approve the Sleeve, they need to make sure they have covered the essentials for the safety of the patient, in their coverage policies NATIONALLY!

If your office has a vested interest in the assistant surgeon or is concerned about their patients paying out of pocket for the assistant surgeon, then everyone needs to send complaints to the ASMBS, AMA, ACS and carriers that are denying the assistant surgeon.

We can not fight this alone and really need support from coders, surgeons, and specialty organizations to make a difference.

If anyone is willing to help us, please e-mail me at dwppm@at tx.rr.com

We can make a difference if we all come together Nationwide.
 
So what do you do when a planned biiopancreatic diversion w/duodenal switch cannot be completed due to complications arising and just sleeve is performed and the patient is Medicare and Medicare does not cover the sleeve. Since the "planned" procedure was a BPD can you bill that out with a modifier 53 (discontinued) and then go back later and finish the BPD - could be even a year later and use the same CPT code?
 
Could you bill the BPD with -53 and instead of billing a sleeve (43775), bill a partial gastrectomy with gastroduodenostomy (43631)? Medicare does cover this code.
 
Does anyone have any updates or insight on payments being made for an assitant surgeon for CPT 43775? We are having this same issue. Another issue is that the insurance companies are saying it's a sameday surgery. Our Dr. tells us its longer than a day but less than 2 days (I'm not exactly sure what he means but when i ask he says 1 1/2 days). Do you bill 43775 as sameday or overnight?
 
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Have you been able to figure out how to get the assistants paid? We just started doing these and have been denied on a couple so far. There is no way this case can be done with an assist. If you have in more info please email at gidneyga@wsspa.com Our doctors are willing to talk to who ever they need to get this going. Thanks or you can reach me at 316-300-2520 thanks Gail Gidney Wichita Surgical CPC
 
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