Wiki Help 43775 LAP SLEEVE GASTRECTOMY

[edavis7]

I billed 43775 to Medicare DOS 1/30/13 and received a denial stating these are non covered service because it's not deem a medical necessity by payer. When I called Medicare for a further explanation of the denial I was referred to the Medicare National Coverage Determination Manual Chapter 1, Section 100.1 which doesn't make since to me. The manual states it's a stand alone code, does that mean you can only bill 43775 alone? The claim was billed according to the guidelines. I was wondering if anyone knows why Medicare is still denying this code. Also if anyone has received payment for this code if so how did you get it paid.

Thanks in advance for your help.

 

[Michele Hannon]

The CPT manual is formatted with two types of codes: stand alone and indented. A stand alone code provides the full description of the code. Stand alone codes precede indented codes. The stand alone verbiage before the semicolon applies to the indented codes that follow.
For example:
Stand alone code 43770 Laparoscopy, surgical, gastric restrictive procedure;placement of adjustable gastric restrictive device, etc.
Indented code-43775 longitudinal gastrectomy (ie, sleeve gastrectomy) includes the description preceding the semicolon above

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/Downloads/MM8028.pdf

You're certain all of the NCD criteria are being met?