Blue Cross and Blue Shield Press Release: Might want to read this one!

[Lap_dancer 8]

I was simply searching Blue Crosses website and found this!

http://www.bcbs.com/betterknowledge/tec/press/

Technology Evaluation Center in the Press

November 2006

The following Assessments and Special Reports were acted on at the November 2, 2006, Blue Cross and Blue Shield Association Medical Advisory Panel (MAP) meeting: Laparoscopic Adjustable Gastric Banding for Morbid Obesity

The MAP concluded that laparoscopic adjustable gastric banding for morbid obesity meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.

[TracyinKS 7]

Thanks! I printed it out and put it with my other documentation!

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and more............ http://mcgs.bcbsfl.com/

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Non-Covered Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION:

In cases where a severe, potentially life threatening condition develops which is documented in the medical record, gastric bypass revision is considered medically necessary and may be eligible for coverage. WHEN SERVICES ARE COVERED:

The following lists examples of conditions AND/OR diagnoses for which gastric bypass revisions may be covered:

• <LI class=bulletedList-1>Weight loss of 20% or more below the ideal body weight (based on the 1996 Metropolitan Life Height & Weight tables Men and Women) <LI class=bulletedList-1>Esophagitis (e.g., esophageal reflux) <LI class=bulletedList-1>Hemorrhage or hematoma complicating a procedure <LI class=bulletedList-1>Vomiting (bilious) following gastrointestinal surgery <LI class=bulletedList-1>Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and bypass) <LI class=bulletedList-1>Stomal dilatation, documented by endoscopy (not UGI) <LI class=bulletedList-1>Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more <LI class=bulletedList-1>Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more <LI class=bulletedList-1>Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery) <LI class=bulletedList-1>Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery), <LI class=bulletedList-1>Severe dumping syndrome <LI class=bulletedList-1>Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome) <LI class=bulletedList-1>Disruption of operation wound <LI class=bulletedList-1>Staple line failure, documented by upper gastrointestinal examination
  
• Disrupted staple line provided there has been prior weight loss.

WHEN SERVICES ARE NOT COVERED:

Gastric bypass revision services are not covered when coverage criteria are not met as described in the WHEN SERVICES ARE COVERED section or when the member's contract does not provide benefits for these services. BILLING/CODING INFORMATION:

CPT Coding:

43848

Revision , open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure)

43850

Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy

43855

Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy

43860

Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy

43865

Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy

43886

Gastric restrictive procedure, open; revision of subcutaneous port component only

43887

Gastric restrictive procedure, open; removal of subcutaneous port component only

43888

Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only

ICD-9 Diagnoses Codes That Support Medical Necessity:

530.1

Esophagitis (esophageal reflux)

536.1

Acute dilatation of stomach (documented by endoscopy, not UGI)

536.1

Pouch dilation (documented by UGI or endoscopy; producing weight gain of 20% or more)

537.6

Stenosis of stomach (after vertical banding documented by endoscopy; producing vomiting or weight loss of 20% or more)

564.2

Postgastric surgery syndrome (i.e., post-gastrectomy syndrome, post-vagotomy syndrome, severe dumping syndrome)

564.3

Vomiting following gastrointestinal surgery

564.4

Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery)

579.3

Other and unspecified postsurgical nonabsorption (i.e., hypoglycemia, malnutrition following gastrointestinal surgery)

783.2

Abnormal loss of weight (20% or more below the ideal body weight according to the 1996 Metropolitan Life Height & Weight tables for men and women)

997.4

Digestive system complications (i.e., complications of intestinal (internal) anastomosis and bypass)

998.11-998.13

Hemorrhage or hematoma complicating a procedure

998.3

Disruption of operation wound (i.e., dehiscence; rupture; staple line failure documented by upper gastrointestinal examination; disrupted staple line, provided there has been prior weight loss)

REIMBURSEMENT INFORMATION:

Refer to section entitled WHEN SERVICES ARE COVERED. PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines. DEFINITIONS:

No guideline specific definitions apply. RELATED GUIDELINES:

Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery), 02-40000-10 OTHER:

To view the Metropolitan Life Height & Weight tables Men and Women, see Surgery for Clinically Severe Obesity (Gastric Bypass), 02-4000-10. REFERENCES:

1. <LI value=1>American Medical Association CPT (current edition) <LI value=2>Florida Medicare Part B Local Medical Review Policy # 11920: Cosmetic/Reconstructive Surgery (01/01/02, retired 02/01/04) <LI value=3>Florida Medicare Part B Local Medical Review Policy # 40000: Digestive System (01/01/02) <LI value=4>Medical Practice and Coverage Committee (BCBSF)
   
2. St. Anthony’s ICD-9-CM Code Book (current edition)

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/23/04. GUIDELINE UPDATE INFORMATION:

10/15/99

New Medical Coverage Guideline.

01/01/02

Coding changes.

12/15/02

Reviewed; typographical corrections.

10/15/04

Scheduled review; no change in coverage statement; added 43848.

01/01/06

Annual HCPCS coding update (revise 43848; add 43886, 43887, and 43888.

Private Property of Blue Cross and Blue Shield of Florida.

This medical coverage guideline is Copyright 2006, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

Internet Privacy Statement | Terms of Use © 2006 Blue Cross and Blue Shield of Florida, Inc.

Date Printed: January 5, 2007: 10:48 PM

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01/01/06

Annual HCPCS coding update (revise 43848; add 43886, 43887, and 43888.

Additional coding for BCBSFL

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Still rolling and storing data and sites:

http://mcgs.bcbsfl.com/ Medical guidelines ( criteria to meet) for BCBS

Medical codes and diagnostic codes

Subject: Gastric Bypass Revision

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Gastric%20Bypass%20Revision#P24_1042

DESCRIPTION:

In cases where a severe, potentially life threatening condition develops which is documented in the medical record, gastric bypass revision is considered medically necessary and may be eligible for coverage. WHEN SERVICES ARE COVERED:

The following lists examples of conditions AND/OR diagnoses for which gastric bypass revisions may be covered:

• <LI class=bulletedList-1>Weight loss of 20% or more below the ideal body weight (based on the 1996 Metropolitan Life Height & Weight tables Men and Women) <LI class=bulletedList-1>Esophagitis (e.g., esophageal reflux) <LI class=bulletedList-1>Hemorrhage or hematoma complicating a procedure <LI class=bulletedList-1>Vomiting (bilious) following gastrointestinal surgery <LI class=bulletedList-1>Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and bypass) <LI class=bulletedList-1>Stomal dilatation, documented by endoscopy (not UGI) <LI class=bulletedList-1>Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more <LI class=bulletedList-1>Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more <LI class=bulletedList-1>Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery) <LI class=bulletedList-1>Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery), <LI class=bulletedList-1>Severe dumping syndrome <LI class=bulletedList-1>Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome) <LI class=bulletedList-1>Disruption of operation wound <LI class=bulletedList-1>Staple line failure, documented by upper gastrointestinal examination
  
• Disrupted staple line provided there has been prior weight loss.

WHEN SERVICES ARE NOT COVERED:

Gastric bypass revision services are not covered when coverage criteria are not met as described in the WHEN SERVICES ARE COVERED section or when the member's contract does not provide benefits for these services. BILLING/CODING INFORMATION:

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Gastric%20Bypass%20Revision#P24_1042

CENTERS for bariatrics BCBS To Your Health Distinction Centers

http://www.fepblue.org/toyourhealth/tyhbdistincentindex.html

HIPAA regulations from BCBS

http://www.fepblue.org/privacyhipaa/hipaareg_mov.html

Federal Employee Program BCBS

http://fep.careenhance.com/portal/index.jsp