Tag: #bariatricsurgery

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

Find this information usefu Follow my blog for more information. #medicalcoding #medicalbilling #payerupdates

Posted in BCBS Empire NY

BCBS: 32BJ Health Fund Plan- Bariatric Surgery and Joint Replacement Surgery

Posted on by KR2Medical Billing

If you are a surgeon that performs bariatric surgery or joint replacement surgery and see 32BJ Health Fund (BCBS) patients in your office, then this important update is for you! The change will take affect for all surgeries done on DOS 01/01/2022 and thereafter.

32BJ Health Fund has partnered with Hospitals in NY, New Jersey, Connecticut, Massachusetts, Pennsylvania, and Florida to implement a Centers of Excellence (COE) Program for Bariatric and Joint Replacement surgeries.

1.Identifying 32BJ Health Fund patients:

32BJ Health Fund patients are easily identified by the prefix “ETRBJ.”, on their insurance card.

2.Coverage for Bariatric Surgery and Joint Replacement Surgery:

Patients will only be covered if the bariatric surgery and/or joint replacement surgery is performed in one of these COE centers. There will be a $0 copay with a 30 day follow up, after surgery.

32BJ Health Fund patients are NOT COVERED for bariatric and joint replacement surgeries performed by a non-COE provider or at a non-COE hospital.

3.Locating a participating COE provider or COE Hospital:

In order to locate a participating COE provider and a COE Hospital, members need to contact: Plan participants may call 32BJ Member Services at (800) 551-3225.

Providers may call Empire Provider Services at (800) 676-2583.

In addition, 32BJ Health fund patients who live within 50 MILES OF COE Hospital, HAVE to perform their surgery performed by a COE provider at a COE hospital.

(More than 90% of 32BJ members live within 50 miles of a COE hospital.)

More information for Providers:

Any provider looking for more information—particularly anyone currently caring for 32BJ plan participants who may be candidates for bariatric or joint replacement surgery—should call Empire Provider Services at 1-800-676-2583.

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