In Context

October 7, 2013

Drill Down – Surgical Management of Morbid Obesity

 RAC Region C contractor Connolly has posted a complex audit review regarding medical necessity for the surgical management of morbid obesity for Inpatient Hospital and Physician providers. Connolly will be looking for overpayments that occurred when a non-covered procedure is reimbursed due to non-necessity. For Inpatient Hospital providers, the contractor will also review for DRG Validation which requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record.

Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) which are defined by ICD-9 codes.

The issue references not only the NCD/LCDs but also the Centers for Medicare & Medicaid Services (CMS) publications such as 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150 - Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity, where the general coverage is listed as follows:

Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (BMI) 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility.

·         Open Roux-en-Y gastric bypass (RYGBP).

·         Laparoscopic Roux-en-Y gastric bypass (RYGBP).

·         Laparoscopic adjustable gastric banding (LAGB).

·         Open biliopancreatic diversion with duodenal switch (BPD/DS).

·         Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).

·         Laparoscopic sleeve gastrectomy. (Effective June 27, 2012, covered at contractor’s discretion.)

RAC issues for the week of October 7 – October 11, 2013:

RAC Region A Performant

Outpatient Hospital

§  Pre-admission Services - JK (CT and NY) - Diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

 RAC Region C Connolly

Inpatient Hospital

§  Surgical Management of Morbid Obesity -Medical Necessity - Inpatient (C003292013) - Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determination and Local Coverage Determinations which are defined by ICD-9 codes. Overpayments exist when a non-covered procedure is reimbursed. The RAC will also review for DRG Validation which requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record.

Physician

§  Surgical Management of Morbid Obesity - Medical Necessity Review - Carrier (C003282013) - Gastrointestinal surgery for obesity, also called bariatric surgery, promotes weight loss by closing off parts of the stomach to make it smaller. The surgical management for the treatment of morbid obesity is considered reasonable and necessary only if the patient meets the definition of morbid obesity which is defined as a body mass index >= 35 and comorbid conditions exist as outlined in the National Coverage Determination and Local Coverage Determinations which are defined by ICD-9 codes. Overpayments exist when a non-covered procedure is reimbursed.

RAC Region D HDI

DME Non-Physician

§  Complex Medical Review of Lower Limb Prosthetics - HDI will be doing a complex medical review of the Lower Limb Prosthetics reviewing the following: lower limb prosthetics within the previous five years, physician order, physician and prosthetics documentation, proof of delivery, and options and accessories related to the prosthetic(s).

§  Overutilization of Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) accessories per Physician - In the Positive Airway Assist (PAP) and Respiratory Assist (RAD) devices LCDs, there is a common table that represents the usual maximum amount of accessories expected to be medically necessary. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.