Gastric Bypass: Look Beyond Obesity for Medical Necessity
Posted on 27. Jul, 2012 by dchandhok in Hot Coding Topics
To ensure that your surgeon gets paid for bariatric surgery, you need to cross all your “T’s” and dot all your “I’s.” Medicare and other payers that follow CMS guidelines require lots of documentation—and even certification—to let you get the job done.
Document Obesity and Treatment
First, you’ll need ICD-9 documentation of morbid obesity. “Based on the medical record, you should list the primary diagnosis as 278.01 (Morbid obesity), and a secondary diagnosis code from category V85 (Body Mass Index [BMI]) indicating a BMI greater than or equal to 35,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.
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In addition to documenting obesity, the medical record must also demonstrate that the patient has previously been unsuccessful with the medical treatment of obesity.
Document Co-Morbid Diagnoses Too
Only obesity and failed treatment are not enough to justify bariatric surgery for a Medicare beneficiary. You also need to show that the patient presents with at least one adverse health concern related to obesity. The following list gives you an idea of the diagnoses that might fit the bill:
- Hypertension—such as 401.x (Essential hypertension)
- Type-II diabetes—250.xx (Diabetes mellitus) with fourth digits 0 (type II or unspecified type, not stated as uncontrolled) or 2 (type II or unspecified type, uncontrolled)
- Coronary heart disease—such as 414.0 (Coronary atherosclerosis)
- Stroke—such as 431
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