Surgery for diabetes

CMS has determined that open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a body mass index (BMI) less than 35 is no longer considered reasonable and necessary. It has been determined that these same procedures do improve health in patients with T2DM with a BMI greater than 35 so they are still considered reasonable and necessary in those situations. These recent determinations apply to services performed on or after February 12, 2009. In order for an approved facility to be paid for inpatient/outpatient bariatric surgery claims the following must be included on the claim:

• a covered ICD-9/HCPCS procedure code (i.e. 44.38, 44.95, 43770, and 43847);
• ICD-9 diagnosis code of 278.01;
• ICD-9 diagnosis code that indicates T2DM (i.e. 250.00, 250.40, and 250.92); and
• ICD-9 diagnosis code for BMI greater than 35 as a secondary diagnosis (i.e. V85.35, V85.37, and V85.4)

This new determination only covers bariatric surgeries. If the claim does not have ICD-9 diagnosis code 278.01 and a covered procedure code is not present, then the claim is not for bariatric surgery and these guidelines should not be used to process the claim.

CCH Chicago Bureau