In patients with a BMI of
25 kg/m2 or greater, further evaluation of risk factors is required. Blood
pressure and lipid levels should be measured, and fasting glucose tested.
Bariatric surgery may be considered in adults who have
not achieved weight loss with dietary or other treatments and who have a BMI of
40 kg/m2 or greater, or for those who have a BMI of 35 kg/m2 or greater with
significant obesity-related comorbidities (e.g., severe hypertension, type 2
diabetes, obstructive sleep apnea).
Bariatric
surgery may also benefit patients with obesity-related comorbidities who have a
BMI of 35 kg/m2 or lower, but it is not routinely recommended for these
patients
3. Medicare
Payment Guidelines:
In response to
the updated USPTF Guidelines and AAFP clinical evidence supporting the benefit
of gastric bypass surgery as a treatment for obesity Medicare updated their
payment policies for this procedure:
(Rev. 2841, Issued: 12-23-13, Effective:
09-24-13, Implementation: 12-17-13)
Covered Bariatric Surgery Procedures for Treatment
of Co-Morbid Conditions Related to Morbid Obesity
Medicare contractors acting
within their respective jurisdictions may determine coverage of stand-alone LSG
for the treatment of co-morbid conditions related to obesity in Medicare
beneficiaries only when all of the
following conditions are satisfied:
·
The beneficiary has a body-mass index (BMI) ≥ 35
kg/m2;
·
The beneficiary has at least one co-morbidity
related to obesity; and
·
The beneficiary has been previously unsuccessful
with medical treatment for obesity.
4.
Revised HCC
Model
In the Final Call Letter, CMS confirmed that they would be
implementing the updated, clinically revised CMS-HCC risk adjustment model
proposed in the Advance Notice for CY2014. The new model expanded the current number of Condition
Categories from 70 to 79.
Under the revised model, the “Metabolic” category was
expanded from one (HCC 21) to three (HCC 21, HCC 22, HCC 23). Given the
prevalence of obesity, the new HCC 22 “morbid obesity” was quickly identified
as a “low hanging fruit” for optimization teams. By coding morbid obesity with
a BMI of 35.0 vs. 40.0 the prevalence rates, A.K.A. payments, to the plans
would greatly increase.
The previous three events were loosely woven together to
form support for the practice and an urban coding legend rose like a phoenix
from the ashes.
HCC 22 includes the following ICD-10 Codes:
|
Do you see a BMI under 40 in the above chart?
Remember clinical, coding and payment guidelines can not be substituted to fit the situation as needed.
