New CPT codes for Lap Band

[DrHekier 0]

Some potentially big news came out a couple of days ago.

Lap Band now has its own CPT code from the AMA!

As many of you know, the way a physician files for a service performed is by providing a CPT code to the insurance company.

When a new service is 'invented' there is generally a several year lag period until a CPT code is assigned. Until that point the physician needs to use an 'unlisted procedure' code which has been the case until now for Lap Band. This creates problems for both the patient and the physician, since the insurance company can essentially say 'this procedure doesn't officially exist' and will assign any value to it that they wish, or just deny it.

The new code is valid January 1, 2006 I am told. It is 43770.

43770 – Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).

In our practice we will probably have people who were denied coverage for the Lap Band being 'investigational' or 'experimental' refile with their insurance company January 1st. However, the new CPT code will probably not help those who have an outright exclusion for morbid obesity surgery on their policy.

[Alexandra 55]

This is EXTREMELY good news for anyone dealing with insurance issues, and thank you very very much for posting it, Dr. Hekier! CPT codes are often guarded like national secrets, for some reason, so I know this will help a great deal.

Do you know if there is a code for adjustments? That's presented problems for me in the past, with the same procedure being billed different ways on different occasions. it'd be great if there were a standard for it.

I'm going to stick this thread in this section because it's really important information. Thanks again!!

[tomorrowsdream 0]

I've been waiting this out with Medicare as I was assured as of the first of Jan. it would be covered. This gives me further hope that the people I heard this from knew this and were not falsely giving me hope. Thanks for putting a ray of sunshine in my day and letting me think I am one step closer to the Band. God Bless for keeping on top of these things. Medicare didn't per se have an exclusion or inclusion for the lap band...it had nothing, but it was allowing gastric bypass in instances I understand. Please don't misunderstand, because I'm sure what criteria had to be met. I was told it would cover lap banding and be self-explanatory in January, so this is excellent news.

[DrHekier 0]

Do you know if there is a code for adjustments? That's presented problems for me in the past, with the same procedure being billed different ways on different occasions. it'd be great if there were a standard for it.

There is no 'permanent/official' CPT code for adjustments as of yet.

[tomorrowsdream 0]

The doctors here in Boise, Idaho won't accept Medicare even if they begin paying for it, which is fine with me considering they have just learned the procedure and have only done 100 lap bands between them. That doesn't instill a lot of confidence. A Dr. Emma Patterson of Portland taught them the surgery, and I am thinking of going there or going to Seatttle to a Dr. Montgomery. I have to make sure first that Medicare will pay, because these physicians have been paid for gastric-bypass (which my dr. says an absolute no to) and not been paid anything for lap banding, so it's self pay as of now.

Can you give me an idea if I'm going about this right. I have had all my tests...sleep study and yes I have sleep apnea and am on C-pap; blood work; ekg, electrocardiogram; CT scan (because my dr. wanted one to check the size of a triple A which is very small still). Will this in any way interfere with my surgery. My dr. doesn't think so but isn't sure. Can you answer that. Also The CT is to check my liver as it hurts. She isn't sure if it is a cyst or just a fatty liver. I imagine if it is fatty I will have to diet to shrink it down on liquids. Would a cyst make the surgery inoperable?

I realize I've asked a lot of questions, but I need some real answers from an expert. Also, does this new coding mean that lap banding will be covered under Medicare for sure? That is all the surgeons are waiting to hear.

Thanks so much for your help. I realize this is merely your opinion, but it would be much appreciated.

Do you have any idea why a liver would hurt to press on it and not hurt if you didn't touch it. I've had my gallbladder removed and the surgeon said she nicked the liver and put dura bond on it but that was 3 years ago, and it didn't hurt then.

[sarabride2006 0]

Anthem BCBS rewrote their medical policy in May of this year and concluded that the lapband is no longer considered investigational. If anyone is having problems with Anthem and needs a copy of their medical policy, please send me an email. I have it saved on my computer at work and would be happy to send!

[dishdiva 5]

There's also a code for band removal, I'm told by my surgeon's office.

[Mona 0]

I first became interested in lap band surgery two years ago. At the time I had United Health Care ins. and they were going to pay 90% of the cost-including follow-ups. However, my insurance changed before I could go through the pre-op process and now I find myself back at square one. My current ins. is BCBS of Tennessee. I have mixed feelings about this insurance (ins.) because I have heard both good and negative about being approved for this procedure. I would love to talk to someone that knows anything about BCBS ins. and what it takes to get approved through them. I have already gone for my consult visit with the Gastric Band Institute of Chattanooga.

[Mona 0]

I realize this is a late reply to your message but I am eager to talk to someone about the BCBS ins. If you have any other helpful info about the approval process then I would love to know.

[Thinjen 0]

'Mona,

Get ready to fight. I have BC/BS of Tennessee. I have been trying to have this done since last July. They denied it...told me to do 6 months of supervised dieting. I did it. Finished-resubmitted everything, including a food journal and 5 years of documented weights. Just found out this week that it is denied again- not medically necessary. That's a bunch of bunk. I just wrote an appeal letter. We'll see. Next, I'll appeal to the insurance board. Then I'll get an attorney. Heck, if it's too much longer, I may be an attorney by then. Let me know what you find out. We'll get through this together.

[margie9852 0]

Hello ,

Deos anyone have United healthcare with Caterpillar Network ,,I have them as my Insurance company and go for my first consult with the doctor on Thursday and I am wondering what to expect .

Margie

[emtbaby4 0]

I Have Bcbs. My Last App. Was Jan 16. And I Just Got Approved On Mon. They Said The Band Is New To There Insurance Company. Thats Why It Takes So Long To Get Aprroved. I Know I Had To Wait. I Hope This Answered Some Of Your Questions. I Will Be Glad To Answer More For You If I Have Te Answer

[emtbaby4 0]

I Have Bcbs. My Last App. Was Jan 16. And I Just Got Approved On Mon. They Said The Band Is New To There Insurance Company. Thats Why It Takes So Long To Get Aprroved. I Know I Had To Wait. I Hope This Answered Some Of Your Questions. I Will Be Glad To Answer More For You If I Have THE ANSWER. WELL I HOPE YOU HAVE A GOOD NITE. I WILL BE ON FOR AWILE

[amycc3 0]

I have BC/BS of Alabama. they are saying that as of right now it is not covered. What is my first step of fighting them on this? I just need a good starting point to get the ball rolling. Thanks, Amy

[emtbaby4 0]

maybe you can have your doctors keep writting letters to your insurance company