June 19, 2016
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
|
|||
|
VBG
|
Gastric restrictive
procedure, without gastric bypass, for morbid obesity; vertical-banded
gastroplasty
|
43842
|
|
|
AGB
|
Gastric restrictive
procedure, without gastric bypass, for morbid obesity; other than
vertical-banded gastroplasty
|
43843
|
|
|
BPD/DS
|
Gastric restrictive
procedure, with partial gastrectomy, pylorus-preserving duodenoileostomy (50
to 100 cm common channel) to limit absorption (BPD/DS)
|
43845
|
|
|
RYGB (proximal)
|
Gastric restrictive
procedure, with gastric bypass for morbid obesity; with short limb (less than
150 cm) Roux-en-Y gastroenterostomy
|
43846
|
|
|
RYGB (distal)
|
Gastric restrictive
procedure, with gastric bypass for morbid obesity; with small intestine
reconstruction to limit absorption
|
43847
|
|
|
Revision RYGB
|
Revision, open, of
gastric restrictive procedure for morbid obesity, other than adjustable
gastric restrictive device (separate procedure)
|
43848
|
|
|
BPD
|
Gastrectomy, partial,
distal; with Roux-en-Y reconstruction
|
43633
|
|
|
Laparoscopic Bypass Procedures
|
|||
|
RYGB (proximal)
|
Laparoscopy,
surgical, gastric restrictive procedure; with gastric bypass and Roux-en Y
gastroenterostomy (Roux limb 150 cm or less)
|
43644
|
|
|
RYGB (distal)
|
Laparoscopy,
surgical, gastric restrictive procedure; with gastric bypass and small
intestine reconstruction to limit absorption
|
43645
|
|
|
Lap
DS, Lap revisions
Lap sleeve
gastrectomy
|
Unlisted
laparoscopy, stomach
|
43659
|
|
|
Laparoscopic Gastric
Restrictive Procedures
|
|||
|
Lap adjustable
gastric band and port implantation
|
Implantation of
adjustable gastric band and port, [Laparoscopic]
|
43770
|
|
|
Lap Sleeve
Gastrectomy
|
Laparoscopy,
surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e.,
sleeve gastrectomy)
|
43775
|
|
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
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 webbservices.lori@gmail.com or you can also find current coding information
on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
*********************************************************************************************
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)
INDICATION FOR PROCEDURE:
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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