Category: Education

Posted in #reimbursement, 1199 SEIU Benefits Fund, Education, NY Providers, Payer Updates

NYS Medicaid: Bariatric Surgery Medical Policy Update

Posted on by KR2Medical Billing

Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you!

Non surgical treatment should be attempted: ex. diet and increased exercise.

Bariatric Surgery Adult Patient: 18 years old and over

  1. BMI index 35 kg/m or greater OR
  2. BMI index 30-34.9 kg/m and a serious weight-related health problem (ex. High blood pressure, type 2 diabetes or severe sleep apnea)
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Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a team of various providers ex. Pediatric provider, bariatric surgeon, and or other specialty providers.

  1. BMI- more and equal to 35 kg/m or more than 120% of 95th percentile of age and sex, whichever is lower AND with a weight-related health problem: ex. diabetes type 2, obstructive apnea – index or Reapiratory Disturbance Index greater than 5, Blount disease, non alcoholic steatohepatitis, slipped capital femoral epiphanies, GERD, hypertension, insulin resistance; or depressed health-related quality of life
  2. BMI greater than 40 kg/m or greater than 140% of the 95th percentile of age and sex, whichever is lower

Coding:

Most common codes that related to Bariatric Surgery

43644: Laparoscopic Roux-en-Y gastric bypass.

43775: Laparoscopic sleeve gastrectomy.

43770: Laparoscopic placement of an adjustable gastric band


43645: Laparoscopic malabsorptive procedure (e.g., [[Mini-gastric bypass|Mini-gastric bypass]]).

43848: Revision of a gastric restrictive procedure (open). 

NYS Medicaid coding and fee resources:

1. Physician Fee schedule- https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.emedny.org%2FProviderManuals%2FPhysician%2FPDFS%2FPhysician_Manual_Fee_Schedule_Sect5.xls&wdOrigin=BROWSELINK

2. Provider Manual- https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician%20Procedure%20Codes%20Sect5.pdf

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Posted in #reimbursement, #unitedhealthcare, Education, Payer Updates, Payers and CPT reinbursement

NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding

Posted on by KR2Medical Billing

Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you!

When: this applies for any services done on/and after Jan 1, 2026.

Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient registry AND the provider must participate in the CMS study related to SCD gene therapies.

3. Which Plans- NJ Managed Medicaid Plans, ex. UHC Community Plan

Billing:

1. Professional Provider must bill on a separate professional claim (HCFA-1500)

2. Facility- drug must not be included on any facility claim, and added to any DRG or APC charges

3. SCD- must not be purchased at 340B program or be dispensed from 340B program inventory

Reimbursement:

4. Claims bust include the corresponding NDC, units, HCPCs and DX codes

Rebursement:

  1. The SCD is reimbursed at an invoice/ acquisition cost- the charges on the professional claim must equal to the Supplier invoice or the drug
  2. If the drug is billed through pharmacy (point of sale), the professional claim will not be reimbursed and will be processed as duplicate

Coding:

Please check out the following links for more coding info of the 2 drugs that fall under this policy:

Click to access billing-and-coding-guide.pdf

Lyfgenia Coding and Billing Resouces

Casgevy Billing and Coding Guide: https://www.casgevyhcp.com/sites/default/files/coding-and-billing-guide.pdf

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