UPDATE: Include Gastric Band Adjustments in E/M Service

November 2nd, 2012

The information below is no longer current: On Nov. 19, 2012 Medicare Part B Carrier Palmetto GBA issued an updated policy instructing coders to report  43999 Unlisted procedure, stomach for gastric band adjustments that occur outside the global period of gastric restrictive procedures. Palmetto now specifies:

“To submit a claim for adjustment of Gastric Restrictive Device:

  • Only reimbursable in the office setting
  • Submit CPT Code 43999 (Unlisted procedure, stomach)
  • Narrative field put the words ‘adjustment of lap-band’

Imaging to locate the port would be included in the service of CPT code 43999.”

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<Note: This information is no longer current, as of 11/19/2012>

When billing for gastric band adjustments outside of the global period of 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty or 43659 Unlisted laparoscopy procedure, stomach for Medicare part B patients in California, Nevada, and Hawaii, you should report only a medically-necessary evaluation and management (E/M) service at the level of 99213 Office or other outpatient visit for the evaluation and management of an established patient…. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Per instructions from Palmetto GBA, Medicare Part B carrier for Jurisdiction 1 (Calif., Nev. Hawaii.), “Prior to making an adjustment, Medicare expects a medically necessary evaluation and management service to be performed. The adjustment is included in the E/M service provided on the date of service for the E/M code billed. Ordinarily this would be at the level of CPT® code 99213.”

The number and frequency of adjustments to the band depends on individual considerations. Most patients have between five and eight adjustments within the first year after surgery. There is no specific HCPCS code that describes these adjustments. You should not report an unlisted procedure code for these adjustments, according to Palmetto, or the claim will be rejected for incorrect coding.


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10 Responses to UPDATE: Include Gastric Band Adjustments in E/M Service

  1. kathy Says:

    In NC we are under Palmetto MCR and got this same memo. However, it is very confusing as 43843 is not the code for the adjustable Lap Band procedure. That code is 43770. So we don’t know if this applies to the lap band adjustments we do or not. Has anyone else gotten clarification on this?

  2. Elizabeth Pierluissi, CPC Says:

    There is a Medicare specific code to bill band adjustment and payable by Medicare. It is CPT 43999 with comment; Band Adjustment, Medicare specific code.
    I work in bariatric program, this is what we normally bill for outside global period band adjustements (fill or unfill). Reimbusement is better, and code appropriate for band adjustments only. Also, there is 10 day global for this type of visit.
    Thanks.

  3. Beth Says:

    We code the 43999 for unlisted procedure for the lap band fill. We get denied, they ask for records then we get paid.

  4. Alicia Says:

    Since there is a temporary national code S2083 (adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline) would this not go against the prospect of using and E&M service for the unlisted procedure for the adjustment of the gastric band.

    I do understand that the E&M service would be included as it would with any minor type office procedure and should not be billed separately unless it meets the modifier 25 requirement; however, I do not believe that an E&M service should be used for the adjustment service because there is a HCPCS Level II, temporary national code S2083 that represents the procedure. The main problem is that Medicare will not accept the temporary national HCPCS codes.

  5. Alicia, CPC Says:

    We as well use the 43999 for the adjustment of the gastric bands and because it is unlisted, Medicare reqeusts the medical records. However, for our commercial payers we do use the S2083.

  6. Cindy Riesenberg CMM,CPC Says:

    The laparoscopic adjustable gastric band surgery that our surgeons perform is CPT code 43770, not 43843. In Kentucky, Medicare Part B has instructed us to use CPT 43999 with comments gastric band adjustment, amount added or removed from band and date of original surgery for any adjustments out of global period. For private insurances, we use S2083. If an adjustment is performed, we only bill for the adjustment, no E&M service. From the comments, it seems this is what most practices do. If different info is being given by Medicare, we need to know where to look this up for clarification. Thanks!!

  7. Abby, CPC Says:

    I agree with Cindy this is what we code as well. They also state on the CGS Medicare website that when billing 43999 for the band adjustment to have the procedure comment state the Surgery date and the p-tan of the Hospital where the surgery was performed. When this information is on the claim we very rarely get records request but we do still get them randomly.

  8. Holly Says:

    It is appropiate to attach an E & M code to the adjustment. The physician must assess the patient first and depending on that exam determines if the patient receives an adjustment. It is not a planned procedure. Physician has to determine if medically necessary for adj. needs mod 25 attached to ov.

    We also bill 43770 for the operative procedure not 43843. 43843 is an open procedure not laparoscopic

  9. Connie Says:

    I’m with everyone else. The band procedure we do is lap band, 43770. When adjustments are done outside the postop period, we bill 43999 to Medicare or S2083 to other carriers.

  10. Michelle Says:

    I have to agree with the responses. We have guidance to use 43999 for Medicare, S2083 for private insurance. I hope this information is clarified in the near future. This is very misleading for new bariatric coders.

    I agree with billing an E&M only if medically necessary. This frequently only happens when the patient presents with an issue (dsyphagia, vomiting, nausua, heartburn etc) and the decision is made to deflate the band.

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