Chapter 2: Bariatric Surgery

Bariatric surgery is the procedure performed on obese people to help them lose weight by reduction in stomach
size that results in reduced food intake and absorption. The most widely used bariatric procedures are the , Rouxen-Y gastric bypass (43644-43645 and 43846-43847) and biliopancreatic diversion with duodenal switch (43845).
Roux-en-Y Won't Involve Gastrectomy
You can usually identify a Roux-en-Y procedure by the inclusion of the term "Roux-en-Y" in the operative report.
This is the most common type of bariatric procedure surgeons now perform.
CPT includes two codes to describe open Roux-en-Y procedures:
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less)
Roux-en-Y gastroenterostomy
43847 ... with small intestine reconstruction to limit absorption.
Code 43846 involves partitioning off a small section of the stomach (usually with staples) and dividing the small
intestines. The surgeon attaches one portion of the small bowel to the new stomach pouch and uses the other
(distal) portion of the bowel to create a "bypass" before rejoining it to the main portion of the small intestine. This
restricts food intake and limits absorption.
Measurements matter: Code 43847 involves a more extensive rerouting of the small intestine (longer than
150-cm limb) to limit absorption further.
Tip: Although the surgeon resects the stomach, she does not remove any portion of it (gastrectomy) during
43846-43847. This is one way to differentiate these procedures from biliopancreatic diversion and biliopancreatic
diversion with duodenal switch.
For Laparoscopic Procedures, Turn to 43644-43645
If the surgeon performs a Roux-en-Y bypass using the endoscope rather than using an open incision from the
breastbone to the navel, you should turn to 43644 (Laparoscopy, surgical, gastric restrictive procedure; with
gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less]) and 43645 (... with gastric bypass
and small intestine reconstruction to limit absorption). These codes are identical to 43846 and 43847, except that
they describe a laparoscopic approach.
Remember: You should never report the open and laparoscopic codes for the same procedure. If the surgeon
converts a laparoscopic procedure to an open procedure, you should report the open procedure code only (see
below for more information).
Biliopancreatic Diversion Includes Gastrectomy
You can identify biliopancreatic diversion with duodenal switch because it involves gastrectomy (removal of a
portion of the stomach) while preserving the pylorus and a short (2- to 4-cm) section of the duodenum. During
Roux-en-Y procedures as described above, the surgeon completely bypasses the duodenum.

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The appropriate code to describe biliopancreatic diversion with duodenal switch is 43845
(Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy
[50 to 100 cm common channel] to limit absorption [biliopancreatic diversion with duodenal switch]).
The "switch" is essential: Biliopancreatic diversion with duodenal switch (DS) differs from simple biliopancreatic
diversion (BPD), which is not a covered procedure for Medicare. Specifically, whereas the BPD involves an
anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the
duodenum and the intestine. More specifically, the DS maintains the presence of the pylorus.
Tip: If the op note is unclear, ask. Don't hesitate to consult with the surgeon if the documentation is unclear as to
the surgery's nature.
Don't Forget Separately Reportable Procedures
Surgeons often remove the appendix during bariatric surgery. You may report the appendix removal separately
using +44955 (Appendectomy; when done for indicated purpose at time of other major procedure [not as separate
procedure] [List separately in addition to code for primary procedure]) as long as medical necessity supports the
procedure.
Surgeons may remove the appendix as a preventive measure during bariatric surgery, but unless the appendix
appears abnormal (with scarring and/or old inflammatory changes, for example), the removal is incidental, and
you should not report +44955 separately.
Cholecystectomy follows similar guidelines: The same rules apply if the surgeon performs cholecystectomy
which is also common during bariatric surgery.
If the patient has cholelithiasis (gallstones) or cholecystitis (an inflamed gallbladder), for instance, you may
legitimately report a separate cholecystectomy (47600).
Laparoscopic Banding Gastric Restrictive Procedures
Laparoscopic gastric restrictive surgery is reported with 43770 (Laparoscopy, surgical, gastric restrictive
procedure; placement of adjustable gastric restrictive device [e.g., gastric band and subcutaneous port
components]).
How it works: During the procedure, the surgeon using laparoscopic techniques places an adjustable
silicone band just below the gastroesophageal junction. The band connects to an access port into which the
surgeon may inject (or aspirate) saline to expand (or contract) the band and effectively manipulate stomach size
(and thus, control appetite suppression, satiety, and weight loss).
Because the surgery requires the physician to place both the adjustable band and subcutaneous port, CPT has
included several companion codes for 43770 to describe subsequent revision or removal of the individual
components, including:

43771 ... revision of adjustable gastric restrictive device component only

43772 ... removal of adjustable gastric restrictive device component only
43773 ... removal and replacement of adjustable gastric restrictive device component only

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Overweight Alone Won't Ensure Coverage

Not every patient will qualify for Medicare coverage of bariatric procedures.
Most substantially, Medicare will not cover bariatric surgery in patients who only have an
obesity diagnosis. Instead, CMS will only provide coverage for patients who present with
various comorbidities, including hypertension, type-II diabetes, coronary heart disease,
stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and certain
types of cancers.
Specifically, CMS guidelines dictate, "Certain designated surgical services for the treatment of
obesity are covered for Medicare beneficiaries who have a BMI > 35, have at least one
comorbidity related to obesity, and have been previously unsuccessful with the medical
treatment of obesity."
Tip: You can specify a patient's body mass index using diagnostic V code series V85.x.
Additionally, the agency determined that the benefit of bariatric surgery "can only be assured
in facilities that do large numbers of these procedures performed by highly qualified
surgeons." Specifically, such facilities must obtain certification from either the American
College of Surgeons or the American Society of Bariatric Surgery.

43774 ... removal of adjustable gastric restrictive device and subcutaneous port components.
You should not report 43772 and 43773 for the same session. Removal and replacement of the gastric restrictive
device (43773) includes removal as described by 43772.
Don't Confuse Revisions and Adjustments
Although appropriately applying 43771-43774 is mostly self-explanatory, you must be careful to make one
distinction: Gastric restrictive device adjustments (by saline injection or aspiration) are not the same as revisions
as described by 43771.
The physician performs adjustments routinely (generally in the office) several times a year to optimize weight loss.
You should include such adjustments to the gastric restrictive device by saline injection/aspiration (which is a
nonsurgical procedure) as a standard postoperative component of 43770 and 43773, according to CPT rules and
the AMA's CPT Changes 2006: An Insider S View.
In other words: You cannot report a separate service for band adjustments during the primary procedures' global
period.
On the other hand, gastric restrictive device revision (43771) involves laparoscopic surgery to manipulate a gastric
device placed during a previous procedure. Such revisions are not routine, and a surgeon would only undertake
such a procedure to manage a complication.
Modifiers, Unlisted Codes Make Up for Gaps
In two circumstances, you still cannot call on a dedicated CPT code to describe a procedure associated with
laparoscopic gastric banding. These include placing either the gastric restrictive device or the subcutaneous port
components only, or removing and replacing both the gastric restrictive device and subcutaneous port
components.
When the surgeon places either the gastric device or port components only, you should report 43770, but append
modifier 52 (Reduced services) to indicate that the surgeon did not perform the complete procedure, according to
CPT guidelines.

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In the second case (when the surgeon removes and replaces both the gastric restrictor and subcutaneous port
components), you must reach for 43659 (Unlisted laparoscopy procedure, stomach), CPT says.
Open Codes Complement Laparoscopic Procedures

Code 43848 describes revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable
gastric restrictive device (separate procedure). As directed by the code descriptor, you should apply 43848 for all
open revisions of gastric bypass procedures, except those involving gastric bypass restrictors.
Parenthetical references direct you to report 43770-43774 (explained above) for laparoscopic revision of gastric
bypass restrictive devices and 43886-43888 (explained below) for open revisions of gastric bypass restrictors.
The open codes mirror somewhat their laparoscopic counterparts 43771-43774, as follows:

43886 Gastric restrictive procedure, open; revision of subcutaneous port component only

43887 ... removal of subcutaneous port component only

43888 ... removal and replacement of subcutaneous port component only.

Just as you should not report 43772 (lap removal of port) and 43773 (lap removal and replacement of port) for
the same session, you should not report 43887 (open removal of port) and 43888 (open removal and
replacement of port) together. Code 43888 includes the work involved in 43887.
Don't Report Lap and Open Codes Together
You should observe correct coding conventions by not reporting both a laparoscopic procedure and the analogous
open procedure for the same session. Instead, you should report only the open procedure.
Example: You should not report 43888 with 43774, according to CPT , because these codes describe different
methods of achieving the same ends (removal and replacement of the subcutaneous port component). If the
surgeon attempts the procedure using the laparoscope but converts to an open procedure, report 43888 only.
In addition: When the surgeon converts from an endoscopic to an open procedure, you should attach V64.41
(Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis.
Such conversions are rare, however, and usually occur when there is little abdominal space, difficult exposure,
bleeding, or other situations that make the laparoscopic approach difficult or unsafe.

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Post-Bariatric Skin Removal

Bariatric surgery often involves excess skin removal subsequent to the main procedure
"to prevent the occurrence of recurring rashes, skin maceration, and yeast infections
that develop in the abdominopelvic fold following extreme weight loss," according to
the AMA's CPT Changes 2007: An Insider's View:

15830 Excision, excessive skin and subcutaneous tissue (includes

lipectomy); abdomen, infraumbilical panniculectomy

+15847 Excision, excessive skin and subcutaneous tissue (includes

lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and
fascial plication) (List separately in addition to code for primary procedure).
CPT instructions limit the use of +15847 as an add-on code with 15830 only. CPT
Changes explains, "Code +15847 was added to allow reporting the various procedures
that might also need to be performed following panniculectomy, including transposition
of the umbilicus, undermining to the coastal margin ... of the rectus diastasis, lateral
contouring imbrication and suction assisted liposuction."
Warning: Code +15847 does not describe a "tummy tuck" or other abdominoplasty
procedures. For these procedures, you should report unlisted-procedure code 17999
(Unlisted procedure, skin, mucous membrane and subcutaneous tissue).
Note also that 15830 and +15847 both include layered closure, complex trunk repair,
and adjacent tissue transfer and arrangement. Therefore, you should not report these
procedures separately.

- Published on 2015-01-01

CPT 2014 American Medical Association. All rights reserved.