Wednesday, July 20, 2016

Understanding Bariatric Surgery: CPT and Surgical Interventions

June 19, 2016
 Originally from my HCPro article

In our society, and medical community, the disease of obesity is considered a major health problem. Unfortunately, the disease process of obesity continues to be a major risk factor for the diagnoses in  many other diseases such as diabetes, hypertension, sleep apnea, arthritis, and many, many more.  Obesity is also medically associated with significant morbidity and mortality risk factors when any type of surgical or operative intervention, or even non-surgical hospitalization is necessary.
Most medical providers define and document obesity by the measurement of body mass index (BMI). The BMI is calculated by dividing a patient's mass (kg) by his or her height (m2). A normal BMI is considered in the range of 18.5-24.9 kg/m2. A BMI of 25-29.9 kg/m2 is considered overweight. A BMI of 30 kg/m2 or greater is classified as obese; this classification is further subdivided into class I, II, or III obesity.  In ICD-10cm, obesity and BMI are now easily identifiable, and should be documented in the patients’ records when obesity is being treated as a stand-alone diagnosis, or as part of a diagnosis with other disease processes that are impacted by obesity.   The ICD-10 codes Z68.xx should be coded in addition to the diagnosis of obesity in the medical record and on your insurance claims. 
Bariatric Surgery Origins
The first effective surgery for obesity in the United States was performed in 1954.  This controversial surgery introduced the jejunoileal bypass.  This “weight loss” surgery was met with controversy, as it did have a large amount of complications, such as extreme malnutrition.   In addition to malnutrition, patients also developed  serious complications secondary to the malabsorption (eg diarrhea, vomiting, eg)  and many required reversal of the bariatric procedure.  These initial complications in the infancy of bariatric medicine, provided the impetus for physicians and surgeons to search for better surgical interventions.  As surgical procedures have progressed and become surgically safer, and with less complications, there has been more acceptance from medical physicians who care for obese patients.  These providers are able to provide better education to the patient,  if a surgical intervention is warranted for morbid obesity diagnoses .   In addition, with better bariatric surgical procedures, especially those that are less invasive,  patients ultimately  have the opportunity for surgical success of elimination of an obesity diagnosis.
Currently, there are four basic concepts/options of choices for patients and physicians to decide upon when moving forward with bariatric surgery:
·         Gastric restriction with adjustable gastric banding  (eg, sleeve gastrectomy)
  • Sleeve gastrectomy
    • In a sleeve gastrectomy, part of the stomach is separated and removed from the body. The remaining section of the stomach is formed into a tube like structure. This smaller stomach cannot hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen your desire to eat. However, sleeve gastrectomy does not affect the absorption of calories and nutrients in the intestines.

  • Gastric restriction with mild nutritional malabsorption (eg Roux-en-Y gastric bypass)
    • The Roux-en-Y gastric bypass,
      • A  small stomach pouch is created with a stapler device and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.

  •  “Combination” surgery, that includes both mild gastric restriction and malabsorption (duodenal switch)
    • Sleeve gastrectomy with duodenal switch
      • In this procedure, the physician performs a “sleeve gastrectomy” which includes a duodenal switch.
      • The stomach is resected and "tubulized" with a residual volume of about 150 ml. This gastric reduction is the food intake restriction component.  The stomach itself, is then resected from the duodenum and connected to the distal part of the small intestine.  Once that is completed, the duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.

·         Laparoscopic adjustable gastric banding
·         “Lap Band” surgery
The laparoscopic adjustable gastric banding procedure, also known as the “Lap Band” surgery,  uses a laparoscopic approach to insert a band containing an inflatable balloon to be placed around the upper part of the stomach then fixed in place. This procedure allows a small stomach pouch to be “created”  above the band with a very narrow opening to the rest of the stomach.

·         A port is then placed under the skin of the abdomen. A tube connects the port to the band. Once in place, the surgeon or physician can adjust the band itself by injecting or removing fluid through the port.  This allows, the balloon to be inflated or deflated to adjust the size of the band, therefore restricting the amount of food that the stomach can hold.  This allows the patient to feel full sooner, but it doesn't reduce the absorption of calories and nutrients.

As with any of the above generalized components of bariatric surgery, there are many variations to each of the above four main types of surgical intervention.   CPT has done a terrific job of giving coders a wide selection of CPT codes to choose from to describe these surgical interventions.   In addition to the CPT codes, the surgeons have also abbreviated the surgeries as below in this table that the  American Society for Metabolic and Bariatric Surgery (ASMBS) put together as a helpful guide for coders to use.

Open Procedures
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
Gastric restrictive procedure, with partial gastrectomy, pylorus-preserving duodenoileostomy (50 to 100 cm common channel) to limit absorption (BPD/DS)
RYGB (proximal)
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 150 cm) Roux-en-Y gastroenterostomy
RYGB (distal)
Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
Revision RYGB
Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
Gastrectomy, partial, distal; with Roux-en-Y reconstruction

Laparoscopic Bypass Procedures

RYGB (proximal)
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en Y gastroenterostomy (Roux limb 150 cm or less)

RYGB (distal)
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption

Lap DS, Lap revisions
Lap sleeve gastrectomy
Unlisted laparoscopy, stomach

Laparoscopic Gastric Restrictive Procedures

Lap adjustable gastric band and port implantation

Implantation of adjustable gastric band and port, [Laparoscopic]
Lap Sleeve Gastrectomy
Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)

Let’s take a look at the operative reports

The first operative report is of a traditional laparoscopic sleeve gastrectomy used by CPT code 43775 -  then we have another laparoscopic sleeve gastrectomy that utilized a “robotic” assisted laparoscopic system for the same sleeve gastrectomy.  When coding for these be aware of what “tools” your provider is using if the procedure is being performed as a traditional laparoscopic surgery, or if the physician is utilizing a laparoscopic robotic system.

When coding these, the traditional operation will only require CPT code 43775; however, it you are utilizing a robotic system you should cod the 43775 as your first line item, then add HCPCS code S2900 at $0.00 to provide transparency to the codes and inform your insurance payers that the surgery was performed with a robotic laparoscope system.  Be aware that inclusion of the HCPCS code S2900 should not be billed as a stand-alone code, nor is it reimbursable for any extra revenue.  It is simply an “informational” code for the payers.  

Operative Report #1: Laparoscopic sleeve gastrectomy (traditional) 
Operative Report #2: DaVinci MIS (robotic)  laparoscopic sleeve gastrectomy
Operative Report #3: Laparoscopic (Lap-Band) gastric band placement
Operative Report #4: Laparoscopic removal of LAP-BAND, due to pregnancy (enlarged uterus)

As you review these operative reports, you will notice that these are all laparoscopic.  At this time, laparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity.  In addition, the laparoscopic sleeve gastrectomy which is also considered a viable surgical option, is also less invasive than a traditional open procedure with a quicker recovery time.  The Lap Band procedure is potentially reversible.  The laparoscopic sleeve gastrectomy is non-reversable. 

ICD-10 and Bariatric Surgery Status

The ICD-10-CM code Z98.84 Bariatric Surgery Status refers to the presence of any of these type of synonyms used in the clinical documentation of the medical record. 
·         bariatric surgery status 
·         gastric banding status  gastric bypass status for obesity
·         obesity surgery status
  • History of bariatric (weight loss) surgery
  • History of bariatric surgery
  • History of diabetes mellitus resolved post bariatric surgery
  • History of diabetes mellitus resolved post bariatric surgery (situation)
  • History of diabetes mellitus resolved post gastric bypass
  • History of diabetes mellitus resolved post gastric bypass (situation)
  • History of gastric bypass
  • Presence of laparoscopic band/ or presence of laparoscopic gastric banding device
If the patient is pregnant, and the patients’ bariatric surgery status is affecting the pregnancy, the ICD-10-CM refers us to use these codes as outlined below.  However, the physician should be sure to notate that the bariatric surgery status is complicating the pregnancy, and in what matter the complications exist.  The provider should clearly reflect any complications to the pregnancy related to the bariatric surgery status. 
O99.84 Bariatric surgery status complicating pregnancy, childbirth and the puerperium
·         O99.840 Bariatric surgery status complicating pregnancy, unspecified trimester
·         O99.841 Bariatric surgery status complicating pregnancy, first trimester
·         O99.842 Bariatric surgery status complicating pregnancy, second trimester
·         O99.843 Bariatric surgery status complicating pregnancy, third trimester
·         O99.844 Bariatric surgery status complicating childbirth
·         O99.845 Bariatric surgery status complicating the puerperium

As a coder, good documentation from your providers help ensure you are able to clearly code and report the operative session(s), with the diagnosis of obesity and all additional diagnoses that are impacted by the obesity (medical necessity).  All of these criteria go hand in hand with good quality patient care and correct coding and billing of claims. By working closely with your providers, you can ensure good clean claims, and reduce your overall risk of audit inquiry and financial recoupment of paid claim services.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:  

Operative Report #1
Laparoscopic sleeve gastrectomy (traditional) 
Patient is prepped and all antiembolic precauations are undertaken and appropriate preop antibiotics are administered via IV. A 12-mm optical trocar is placed under direct vision approximately 15 cm below the xiphoid and 3 cm to the left of midline
A 45-degree angled laparoscope is placed through the port into the peritoneal cavity and 12-mm port is placed in the left lateral flank, medial to the edge of the colon with the patient in a supine position and at the same level as the periumbilical port. Next, a 5-mm trocar port is placed along the left subcostal margin between the xiphoid process and the left flank port. Another 12-mm port is placed in the right epigastric region and a fourth 12 mm port was placed in the mid-epigastric region caudal and medial to the previous port. The liver is elevated and this provides adequate visualization of the entire stomach .
The pylorus of the stomach is then identified and the greater curve of the stomach elevated. An ultrasonic scalpel is then used to enter the greater sac via division of the greater omentum. The greater curvature of the stomach is then dissected free from the omentum and the short gastric blood vessels using the laparoscopic ultrasonic scalpel.
The dissection is started 5 cm from the pylorus and proceeds to the Angle of His .  A 9.8 mm gastroscope is then passed under direct vision through the esophagus, stomach, and into the first portion of the duodenum. The gastroscope is aligned along the lesser curvature of the stomach and used as a template to perform the vertical sleeve gastrectomy beginning 2 cm proximal to the pylorus and extending to the Angle of His.
An endoscopic linear cutting stapler is used to serially staple and transect the stomach staying just to the left and lateral to the endoscope. The gastrectomy is visualized with the endoscope during the procedure. The transected stomach, which includes the greater curvature, is completely freed and removed from the peritoneum through the left flank port incision . The staple line along the remaining tubularized stomach is then tested for any leak through insufflations with the gastroscope while the remnant stomach is submerged under irrigation fluid. The staple line is concurrently evaluated for bleeding both intraperitoneally with the laparoscope as well as intraluminally with the gastroscope. A 19-French Blake drain is left in the left upper quadrant along the sleeve gastrectomy staple line. Closure of the fascia t the left flank port site is performed with an absorbable suture on a transabdominal suture passer, to prevent bowel herniation.  We did not close the fascial defects at the remaining port sites.
Patient is taken to PACU in good condition.

CPT code:
43775:  Longitudinal gastrectomy (ie sleeve gastrectomy)

Operative Report #2 
DaVinci MIS (robotic)  laparoscopic sleeve gastrectomy
The Veress needle technique was used to establish the pneumoperitoneum into the left hypochondrium. A 12 mm port was inserted 120 mm inferior and slightly left to the sternum for camera access. For the latter port, we used an extra large 150 mm long trocar The right 12 mm working port was positioned 6 cm from the midline trocar. The left 12 mm working port was located 6 cm to the left of the midline trocar. An 11 mm trocar was placed laterally to the left hypochondrium and an 8 mm da Vinci trocar was placed under the right hip as laterally as possible to allow liver retraction. The 8 mm da Vinci trocars were inserted through standard, disposable 12 mm trocars. This double-cannulation technique was used asstandard 12 mm trocars are required during the insertion of the staples. All trocars are inserted under direct visualization with the da Vinci system camera
We began recording the docking time of the Robot.  The robotic camera was locked last but was used to insert all robotic cannulas and instruments. The robotic cart was positioned over the patient’s head. Once the general setup was ready, the procedure began with myself using a grasper in the left hand and a modified harmonic scalpel in the right hand. The third da Vinci arm used another forceps in order to retract the liver from the 8 mm trocar placed in the right-hand side of the patient. The greater curvature of the stomach was sectioned at the lowest point in order to reach the lesser epiploic sac. During this stage of the procedure, we are completely robotic.   The division of the gastrocolic and gastrosplenic ligament continued exactly as in a standard LSG. With care, we ensure precision in the upper part of the stomach, and avoided any injury to the spleen and had adequate visualization of the vessels. Dissection continued to 5 cm from the pylorus following dissection of the upper part of the stomach.
Next, the assistant surgeon inserted a 32 Fr bougie to calibrate the sleeve. The anesthesiologist did not encounter any difficulty placing the bougie with the robotic bedside cart. A Echelon 60 Endopath stapler, endoscopic linear cutter straight, loaded with a green cartridge, was used to divide the stomach from the lowest tip of the greater gastric curvature;  5 cm proximally to the pylorus, towards the lateral edge of the bougie. This maneuver was performed twice. The right arm was again docked and the left robotic arm was switched to the left lateral 11 mm trocar. This maneuver allowed the decannulation of the right arm from the 12 mm trocar without moving the robot.   We then inserted a stapler loaded with blue cartridges to divide the sleeve up to the end of the upper part. The stomach was then removed from the cavity through the 12 mm trocar. A robotic continuous polypropylene suture (3/0) was used to oversew the entire sleeve staple line.. The first assist then filled the sleeve with diluted methylene blue to detect any leakage from the staple line.  No leaks were encountered, and operative session was complete.  Patient taken to PACU in good condition. 
CPT code:
43775:  Longitudinal gastrectomy (ie sleeve gastrectomy)
S2900: Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure)

Operative Report #3
Laparoscopic (Lap-Band) gastric band placement
The procedure consisted of laparoscopic placement of a gastric band (Lap-Band System), creating a proximal 15-mL pouch at the cardia.
The patient was positioned in an elevated recumbent position. The video monitor was located beyond the patient’s right shoulder.  Pneumoperitoneum was created using a Palmer-Veress needle. The 10-mm optical trocar was inserted first, 10 cm below the xiphoid notch. Then, three 10-mm cannulas were placed under the rib margin.  The fourth cannula on the left had a larger diameter (18 mm) to allow the introduction of the band. All cannulas were then shifted to the left when preoperative (re-review) ultrasound revealed an enlarged left liver lobe (>15 cm high) in the patient. A 10-mm liver retractor was inserted through a paraxiphoid cannula and the left lobe was elevated to expose the cardiac area and the diaphragmatic crus.
Gastric dissection started at the angle of the cardia by division of the phrenogastric ligament. We proceeded with the lap band procedure with a pars flaccida approach on the right side.  Dissection on the left side was identical to that performed on the right. Over the lesser omentum, we opened the peritoneal sheet close to the edge of the right crus, then gradually created a retrogastric tunnel reaching the left crus and the phrenogastric ligament. Thus avoiding tthe use of a balloon.  The band was secured by an anterior gastrogastric valve using four nonabsorbable seromuscular stitches.   .  This covered the anterior part of the band completely. A methylene blue dye test was carried out with no leaks detected.  The subcutaneous port components were then placed and verified as per our pre-operative marking.   Patient was taken to PACU in good condition. 
CPT Code: 43770: Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)

Operative Report #4
Laparoscopic removal of LAP-BAND, due to pregnancy (enlarged uterus)

This is a 27-year-old female who approximately 3 years ago had an adjustable gastric band placed laparoscopically.  She did well and lost over 100 pounds and subsequently became pregnant with twins.  At approximately 22 weeks' gestation, she started having nausea and vomiting and could not hold food down.  She had some morning sickness in the first trimester, which resulted in multiple bouts of nausea and vomiting, which may have been the etiology of initial slip of her band.  Slip of the band was confirmed during upper GI swallow.  She was referred by Dr.____, with the aforementioned findings requesting in consultation. 

In consultation, it was recommended the band could be put back in place and/or removed, and the patient requested removal of the band.

DESCRIPTION OF PROCEDURE: the abdomen was prepped and draped in the normal sterile fashion, a transverse 1 cm incision was made in the right upper quadrant approximately 1-inch medial to the anterior axillary line and 1 to 1-1/2 inches below the costal margin.  A 5 mm Optiview port was then advanced through the subcutaneous tissue, abdominal wall muscle, and immediately upon advancing through the abdominal wall muscle, encountered the uterine muscle, at which point the blunt trocar was removed.  A different angle tried and subsequently again the uterus encountered.  At this point, an additional incision approximately 2 inches lateral to the incision very near the costal margin was made, and a 5 mm port was able to be placed in the abdomen and insufflated.  Two small muscular lacerations on the right upper portion of the uterus were noted.  Under direct visualization, a 15 mm port was placed in the left upper quadrant directed towards the esophageal hiatus in the midclavicular line approximately 2 cm inferior to the costal margin.  In the epigastrium very near the xiphoid and just deviated to the left, an additional 5 mm port was placed, and a liver retractor was placed, retracting the left lobe of the liver anteriorly.  The patient was placed in reverse Trendelenburg, and a 5 mm port was placed through the original attempted site placement.  All instruments were used in the upper third of the abdomen as the lower two thirds of the abdomen were completely taken up by the very large uterus.  The gastric band tubing was identified, and it was elevated.  Scar tissue of omentum and adipose tissue were divided over this and taken down through the point of the buckle, which was opened.  The band was then adequately freed, the tubing cut, and the buckle opened completely by pulling the tubing through.  The wide part of the locking portion of the buckle, which was anterior, was then divided, which allowed the band to be removed without pressure or difficulty.  It was pulled out through the 15 mm port site in 3 pieces.  The remaining tubing will be pulled out with the subcutaneous port when this is dissected from its left lateral position. 

The ports were then removed under direct visualization, noting no bleeding at any of the port sites.  The liver retractor had been removed prior to moving the ports under direct vision without injury to intraabdominal contents.  The fascia in the 15 mm port site was closed with a figure-of-eight stitch of 0 Monocryl.  The skin directly in the old incision very close to the port was infiltrated with local anesthetic, and a 3 cm incision was made dissecting down and identifying the port.  The port capsule and suture was then dissected free of surrounding tissue and removed along with the port and the tubing.  The skin was then closed at this site with simple interrupted buried sutures of 4-0 Monocryl as was the remainder of the laparoscopic sites.  The skin and all incisions were sealed with Dermabond.

CPT code: 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable
gastric restrictive device and subcutaneous port components

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