Abstract:
The sleeve gastrectomy (SG) involves excision of the lateral aspect of the stomach, leaving a much reduced, lesser-curve based, tubular stomach (Hutter, 2011). When this procedure is performed laparoscopically the term laparoscopic sleeve gastrectomy (LSG) is used. Presently, LSG is commonly used as a stand-alone approach to bariatric surgery; however, initially, the procedure served to reduce gastric capacity and initiate short-term weight loss while the malabsorptive component of the operation (biliopancreatic diversion) provided the long-term weight loss (Brethauer, 2011). A stand-alone sleeve gastrectomy is sometimes referred to as an isolated sleeve gastrectomy. A laparoscopic approach to sleeve gastrectomy was later developed. There are variations in the detail of the sleeve gastrectomy procedure itself. Although LSG has been gaining popularity over the last few years and the number of bariatric surgery units that offer it is increasing, there is not yet a standard technique for this procedure (Ferrer-Márquez, 2012).
Obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, is recognized as an important risk factor for morbidity and mortality associated with a number of chronic diseases such as heart disease and diabetes (Flegal, 2010). The Centers for Disease Control and Prevention (CDC) reported that obesity rates in the U.S. have increased dramatically over the last 30 years, and obesity is now epidemic in the United States (Kahn, 2009). For adults 60 years and older, the prevalence of obesity is about 37% among men and 34% among women (NHANES - National Health and Nutrition Examination Survey). Obesity may be further classified according to the National Institutes of Health (NIH):
- Class I Obesity = BMI 30.0-34.9 kg/m²
- Class II Obesity = BMI 35.0-39.9 kg/m²
- Class III (Extreme) Obesity = BMI ≥ 40.0 kg/m²
Indications and Limitations:
National Government Services, Inc. will cover stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.
A. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2,
B.The beneficiary has at least one co-morbidity related to obesity, and
C. The beneficiary has been previously unsuccessful with medical treatment for obesity.
Documentation of outcomes for all bariatric procedures is required for the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited hospitals.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Claims must include three (primary, secondary and tertiary) ICD-10-CM codes as indicated below:
- The primary ICD-10-CM code of E66.01 for morbid obesity;
- A secondary ICD-10-CM code Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43 Z68.44, Z68.45 describing a body mass index; and
- A tertiary ICD-10-CM code describing the co-morbid condition.
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
CMS has determined the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries.
For claims submitted to the Part A MAC:
For inpatient hospital claims, ICD-10-CM procedure code 0DB64Z3 should be reported when conditions A-C (specified above in the “Indications and Limitations” section) are satisfied
CMS National Coverage Policy:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
CMS Publications:
CMS Transmittal 158, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Change Request 8484, December 23, 2013 and CMS Transmittal 2841, Publication 100-04, Medicare Claims Processing Manual, Change Request 8484, December 23, 2013 advises effective for dates of service on and after September 24, 2013, facility certification shall no longer be required for coverage of covered bariatric surgery procedures.
CMS Transmittal 157, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Change Request 8484, November 15, 2013 and CMS Transmittal, Publication 100-04, Medicare Claims Processing Manual, Change Request 8484, November 15, 2013 advises effective for dates of service on and after September 24, 2013, facility certification shall no longer be required for coverage of covered bariatric surgery procedures.
CMS Transmittal No. 2590, Publication 100-04, Medicare Claims Processing Manual, Change Request #8028, November 9, 2012 advises that effective for claims with dates on or after June 27, 2012, Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all three of the conditions are satisfied.
Sources of Information:
This bibliography presents those sources that were obtained during the development of this article. National Government Services is not responsible for the continuing viability of Web site addresses listed below.
Brethauer SA. Sleeve gastrectomy. Surg Clin North Am. 2011;91(6):1265-1279.
Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2.)
Ferrer-Marquez M, Belda-Lozano R, Ferrer-Ayza M. Technical controversies in laparoscopic sleeve gastrectomy. Obes Surg. 2012;22(1):182-187.
Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-421.
Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254:410-420.
