LCD Reference Article Billing and Coding Article

Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after the Global Period

A53444

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A53444
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after the Global Period
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manuel, Chapter 1, Part 2, §100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity

Article Guidance

Article Text

**Only payable in an office setting **

The laparoscopic gastric band is an adjustable and reversible bariatric surgery procedure. The band is an inflatable doughnut-shaped ring. The diameter, which can be adjusted in the office setting by adding or removing saline via a port, is positioned beneath the skin. The number and frequency of adjustments to the band depends on individual consideration(s). Most patients have between 5 and 8 adjustments within the first year after surgery. Claims for an adjustment of a gastric restrictive device after the global period (90 days after surgery) may be reimbursable in the office setting.

An adjustment of the gastric band (CPT® code 43999) and an evaluation and management service (E/M) service are not payable on the same day of service. An E/M and the adjustment of a gastric band (CPT® code 43999) will only be allowed on the same day if there was a significantly separate service provided. The CPT® modifier 25 should be appended to the E/M code to indicate the E/M service was a significantly separate service.

To submit a claim for adjustment of Gastric Restrictive Device:

  • Submit CPT® Code 43999
  • Narrative field put the words 'adjustment of lap-band'


NOTE:

Only reimbursable in the office setting.

Imaging to locate the port would be included in the service of CPT® code 43999.

Response To Comments

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Coding Information

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CPT/HCPCS Codes

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(1 Code)
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Group 1 Codes
Code Description
43999 UNLISTED PROCEDURE, STOMACH
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CPT/HCPCS Modifiers

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Group 1 Codes
Code Description
25 SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE: THE PHYSICIAN MAY NEED TO INDICATE THAT ON THE DAY A PROCEDURE OR SERVICE IDENTIFIED BY A CPTCODE WAS PERFORMED, THE PATIENT'S CONDITION REQUIRED A SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE ABOVE AND BEYOND THE OTHER SERVICE PROVIDED OR BEYOND THE USUAL PREOPERATIVE AND POSTOPERATIVE CARE ASSOCIATED WITH THE PROCEDURE THAT WAS PERFORMED. THE E/M SERVICE MAY BE PROMPTED BY THE SYMPTOM OR CONDITION FOR WHICH THE PROCEDURE AND/OR SERVICE WAS PROVIDED. AS SUCH, DIFFERENT DIAGNOSES ARE NOT REQUIRED FOR REPORTING OF THE E/M SERVICES ON THE SAME DATE. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -25 TO THE APPROPRIATE LEVEL OF E/M SERVICE, OR THE SEPARATE FIVE DIGIT MODIFIER 09925 MAY BE USED. NOTE: THIS MODIFIER IS NOT USED TO REPORT AN E/M SERVICE THAT RESULTED IN A DECISION TO PERFORM SURGERY. SEE MODIFIER -57.
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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R7

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 43999. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

Under CMS National Coverage Policy added regulation CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manuel, Chapter 1, Part 2, §100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity and added description to regulation SSA 1833(e). Formatting was corrected throughout the article. This revision is retroactive effective for dates of service on or after 1/1/23.

 

10/31/2019 R6

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the titile from “Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after the Global Period: Coding and Billing Instructions” to “Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after the Global Period”. Under CMS National Coverage Policy added regulations. Under CPT/HCPCS Modifiers Group 1: Codes added modifier 25. Formatting, punctuation and typographical errors were corrected throughout the article.

02/26/2018 R5 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
10/19/2017 R4

Under Article Text corrected a grammatical error.


 

 

11/23/2016 R3 Annual validation performed-no changes made.
12/03/2015 R2 Under Article Text made a few punctuation corrections and added the word "NOTE" in front of the statement 'only reimbursable in the office setting'.
10/01/2015 R1 Added CPT Code from Article Text to the CPT Coding Section.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Public Versions
Updated On Effective Dates Status
01/10/2023 01/01/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Gastric Restrictive Device
  • Gastric