CPT Code for Lap DS

For those that have had lap DS, do you know what code you Dr. used?  I have searched at the only code I have they say is for open DS.  I know that Medicare makes no distinction between the two. I was just wondering if CPT codes make a distinction.  If not, can the insurance company say that they don't cover a code, if there is no code for a particular procedure? Thanks, Jinjer

Have you asked them?  They should have a table of procedures and codes.   I never had to know any codes at all.  I asked my insurance if they cover the DS and they were able to tell me that and what other procedures they covered by name (no codes). 

I can't find a distinction either. The only code I could locate was revised in 2005 to the following: 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) Do let us know if you learn something new. Rock

This also might interest you in regards to medicare, albeit, lengthy: http://tinyurl.com/zwxqr "Bariatric Surgery for Morbid Obesity Provider Action Needed Impact to You This article is based on Change Request (CR) 5013, which modifies the Medicare National Coverage Determination Manual (NCDM, Sections 40.5 and 100.1) and adds section 150 to Chapter 32 of the Medicare Claims Processing Manual to be consistent with the new Centers for Medicare & Medicaid Services (CMS) policy for bariatric surgery. What You Need to Know Effective for services on or after February 21, 2006, Medicare will cover 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) if certain criteria are met and the procedure is performed in an approved facility. In addition, effective for services performed on or after February 21, 2006, Medicare has decided that open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, and open adjustable gastric banding are nationally non-covered for Medicare. Background Bariatrics is the branch of medicine dealing with obesity, and bariatric surgery can be an effective treatment for patients who have been unsuccessful with diet and exercise and have comorbid conditions such as: Coronary artery disease; Diabetes; and Sleep apnea. Bariatric surgery procedures are performed to treat many comorbid conditions associated with obesity, and two types of surgical procedures are employed: Malabsorptive surgical procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and adsorption of nutrients cannot occur; and Restrictive surgical procedures restrict the size of the stomach and decrease intake. Some surgeries combine both of these types of procedures, and brief descriptions of bariatric surgery procedures are included in the Additional Information section of this article. Also, see the Medicare National Coverage Determinations Manual (Pub. 100-03, Chapter 1, Part 2, Section 100.1 (Bariatric Surgery for Morbid Obesity (Effective February 21, 2006), Subsection A (General)), attached to CR 5013. Note: Bariatric surgery is recommended only for individuals with health concerns related to their obesity CMS has determined the evidence is adequate to conclude that: If a Medicare beneficiary has documented in their medical record that they: Have a body-mass index (BMI) > 35, with at least one co-morbidity related to obesity; and Have been previously unsuccessful with medical treatment for obesity; Then the following procedures (performed on or after February 21, 2006) are considered reasonable and necessary:
Open and laparoscopic Roux-en-Y gastric bypass (RYGBP);
Laparoscopic adjustable gastric banding (LAGB); and
Open and laparoscopic biliopancreatic diversion (BPD) with duodenal switch (DS). Approved Facilities In addition, CMS has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities certified by: The American College of Surgeons ((ACS) http://www.facs.org/cqi/bscn/) as a Level 1 Bariatric Surgery Center (BSC; program standards and requirements in effect on February 15, 2006); or The American Society for Bariatric Surgery ((ASBS) http://www.asbs.org/) as a Bariatric Surgery Center of Excellence (BSCOE; program standards and requirements in effect on February 15, 2006). A list of approved facilities and their approval dates will be listed and maintained on the CMS coverage Web site at http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp#TopOfPage. This information will also be published in the Federal Register. When services are performed in an unapproved facility, Medicare will deny the claim with a claim reason adjustment code of 58. (Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.) For providers to avoid liability for charges when services are performed in an unapproved facility, physicians must have the beneficiary sign an Advanced Beneficiary Notice (ABN), and hospitals, including critical access hospitals, must have the beneficiary sign a Hospital Issued Notice of Non-coverage (HINN). Non-Covered Procedures The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary; therefore, the following procedures are non-covered for all Medicare beneficiaries: Open vertical banded gastroplasty Laparoscopic vertical banded gastroplasty Open sleeve gastrectomy Laparoscopic sleeve gastrectomy Open adjustable gastric banding Changes in Manuals The Medicare Claims Processing Manual (Pub.100-04, Chapter 32 (Billing Requirements for Special Services), Section 150 (Billing Requirements for Bariatric Surgery for Morbid Obesity)) is being added to reflect the new coverage for bariatric surgery. In addition, the Medicare National Coverage Determination Manual (NCDM, Pub. 100-03, Chapter I, Sections 40.5 and 100.1) are being modified to be consistent with the new CMS policy for bariatric surgery. These revisions are attached to CR 5013. The revision of the NCDM will include a reference to the covered surgical procedures, and revise the obesity policy with the final bariatric surgery policy. The modified obesity policy will read as follows (changes bolded and italicized): “Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Non-surgical services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions. Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI ≥ 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity.” Treatments for obesity alone remain non-covered, and the following noncoverage determinations in the National Coverage Determination Manual (NCDM, Chapter 1, Part 2; http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part2.pdf) remain unchanged: Section 100.8 (Intestinal Bypass Surgery); and Section 100.11 (Gastric Balloon for Treatment of Obesity). Additional Instructions CR 5013 further instructs your carrier and/or fiscal intermediary to: Accept the following CPT codes as of February 21, 2006: 43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components) 43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) 43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report CPT code 43645 in conjunction with CPT codes 49320, 43847.) 43845 - Gastric restrictive procedure with partial gastrectomy, pyloruspreserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) 43846 - Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use CPT code 43847)( For laparoscopic procedure, use CPT code 43644) 43847 - With small intestine reconstruction to limit absorption; Accept CPT codes 43770, 43644, 43645, 43845, 43846 and 43847 submitted with at least one of the following diagnosis codes: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4; or 278.01. (Claims will be denied without an appropriate diagnosis code.); Accept International Classification of Diseases, Ninth Revision (ICD-9) procedure codes 44.38, 44.39, 44.95, 43.89, 45.51, and 45.91, when the following diagnosis codes are reported: V85.35; V85.36; V85.37; V85.38; V85.39; V85.4; and 278.01. (Claims will be denied without an appropriate diagnosis code and none of the V diagnosis codes for BMI ≥ 35 or 278.01 for morbid obesity can be the principal diagnosis on an inpatient Medicare claim); and Accept the following ICD-9 Procedure Codes as of February 21, 2006: 44.38 - Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y); 44.39 - Other Gastroenterostomy (open Roux-en-Y); and 44.95 - Laparoscopic gastric restrictive procedure (laparoscipic adjustable gastric band and port insertion). Important Note: There is not a distinction between laparoscopic and open biliopancreatic diversion (BPD) with duodenal switch (DS) for the inpatient setting. The codes would apply to the open approach as follows:
43.89 Other partial gastrectomy;
45.51 Isolation of segment of small intestine; and
45.91 Small to small intestinal anastomosis. Should claims be denied for failure to have the appropriate diagnosis code, the carrier/FI will use claim adjustment reason code #167 to denote “This/these diagnosis(es) is (are) not covered.” Note that 44.68 (Laparoscopic gastroplasty (vertical banded gastroplasty)) is noncovered for Medicare effective February 21, 2006."

I have asked the insurance, and the only code they have is for DS, no distinction between lap and open.  When my Dr's office called to get my benefits, they were told there was no code for the lap DS and they did not cover non code procedures.  When I called the insurance company and gave them the only code I could find, which the the same one you  mention, they said that it has to go through medical review.   I have also bookmarked the Medicare coverage statement, should I need to appeal. Thanks to everyone for the help. Jinjer