MLN Matters® Number: MM6419 Revised
Related Change Request (CR) #: 6419
Related CR Release Date: May 4, 2009
Effective Date: February 12, 2009
Related CR Transmittal #: R100 NCD and R1728CP
Implementation Date: May 18 2009
Note: This article was revised on August 21, 2009, to show the correct Group Code of 'CO' (Contractual Obligation). All other information remains the same.
Provider Types Affected
All hospitals and physicians who bill Palmetto GBA for bariatric surgery procedures.
Provider Action Needed
Providers are advised that the Centers for Medicare & Medicaid Services (CMS) has developed the following National Coverage Determination (NCD) entitled Surgery for Diabetes:
- Effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a body mass index (BMI) <35 are not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act, and therefore are not covered by Medicare.
- Effective for services performed on and after February 12, 2009, CMS determines that open and laparoscopic RYGBP, open and laparoscopic BPD/DS, and LAGB are covered for Medicare beneficiaries who have T2DM and a BMI = 35. Additionally, CMS determines that T2DM is a comorbidity related to obesity as defined in Publication 100-03, NCD Manual, and section 100.1. In addition, the procedure must be performed at an approved facility. A list of approved facilities may be found at www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage.
Ensure that your billing staffs are informed of these changes for preparing claims for covered or non-covered bariatric surgery.
Background
CMS has a specific NCD at section 100.1 (attached to CR 6419), Bariatric Surgery for Treatment of Morbid Obesity, effective February 21. 2006. That NCD covers open and laparoscopic RYGBP, open and laparoscopic BPD/DS, and LAGB for persons with a BMI =35 having one or more comorbidities associated with obesity, and have been previously unsuccessful with medical treatments for obesity. The only change to this NCD is the clarification that effective February 12, 2009; T2DM is considered comorbidity for purposes of bariatric surgery for the treatment of morbid obesity.
Note: This NCD does not change related NCDs in the NCD Manual at sections 40.5 (Obesity), 100.8 (Intestinal Bypass Surgery), or 100.11 (Gastric Balloon for Treatment of Obesity). In addition, treatments for obesity alone remain non-covered, as does use of the open or laparoscopic sleeve gastrectomy, open adjustable gastric banding, and open and laparoscopic vertical banded gastroplasty procedures, regardless of the patient’s BMI or comorbidity status.
The covered ICD-9 procedure and HCPCS procedure codes are listed in Attachment 1 of the transmittal of CR 6419 containing the Medicare Claims Processing Manual revisions. The ICD-9 diagnosis codes reflecting the requisite BMI indexes are also part of that attachment. The ICD-9 diagnosis codes indicating T2DM are listed in Attachment 2 of that same transmittal.
The remittance advice for claims for bariatric surgery that are denied or rejected by Medicare because the patient’s BMI was <35 will contain a Claim Adjustment Reason Code of 167 (This (these) diagnosis(es) is (are) not covered.), a Remittance Advice Remark Code of N372 (Only reasonable and necessary maintenance/service charges are covered.), and a Group Code of CO (Contractual Obligation).
Additional Information
If you have any questions, please contact our provider service center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.