Knowledge Base Article

The March 1, 2018 edition of the Medicare Learning Network e-newsletter mlnconnects, includes a list of new and revised Provider Compliance Tips Fact Sheets. This article focuses on the new Provider Compliance Tips for Bariatric Surgery Fact Sheet.

Provider Compliance Tips for Bariatric Surgery Fact Sheet

CMS notes there is a National Coverage Determination (NCD) 100.1 for Bariatric Surgery for Treatment of Obesity. As a matter of fact this NCD is now in its 5th iteration with the first version having an effective date of 10/1/1979.  

Bariatric procedures are performed to treat the comorbid conditions associated with morbid obesity and a beneficiary must meet all of the following Medicare coverage criteria:

• Have a Body-Mass Index (BMI) of ≥ 35 kg/m2,
• At least one comorbidity related to obesity, and
• Had prior unsuccessful medical treatment for obesity.

Bariatric surgery as treatment for obesity alone remains non-covered by Medicare.

Reasons for denials cited in the fact sheet include insufficient documentation, documentation fails to support procedures as reasonable and necessary, and Providers do not comply with signature requirements.

Bariatric Surgery Medical Necessity Reviews

Bariatric Surgery is not new, so the question for me is why a Fact Sheet now? More importantly, for hospitals performing bariatric procedures, have you self-audited medical record documentation to validate that procedures being performed are reasonable and necessary? If not, you should because what I have found in writing this article is that Medicare Auditors have and continue to review these procedures for medical necessity.

Comprehensive Error Rate Testing (CERT)
The Fact Sheet includes the July 2014 edition of the Medicare Quarterly Compliance Newsletter as a resource for more information about bariatric surgery. The newsletter includes an overview of a special study of HCPCS codes for bariatric surgery (43644 and 43770) conducted by the CERT. They found that insufficient documentation (something was missing from the record) caused approximately 98 percent of the improper payments. The newsletter also provides examples of improper payments for bariatric surgery.

Supplemental Medical Review Contractor (SMRC): Completed Project 2015-0216 Bariatric Surgery

The SMRC completed a review of bariatric surgery for the treatment of morbid obesity at the direction of CMS as a result of the 2014 CERT special study. The Project included a review of claims with dates of service from January 1, 2014 through December 31, 2014.

In their report they noted that CMS identified Type 2 diabetes mellitus as being one co-morbidity related to obesity and go on to indicate that CMS delegated the authority to determine additional co-morbidities and whether coverage will be extended to other types of bariatric surgery than outlined in NCD 100.1 to the Medicare Administrative Contractors (MACs).

At the time this project was completed, co-morbidities covered by one or more MAC included:

• Refractory hypertension (HTN),
• Obesity-induced cardiomyopathy,
• Clinically significant obstructive sleep apnea,
• Obesity-related hypoventilation,
• Pseudo tumor cerebri (documented idiopathic intracerebral HTN),
• Severe arthropathy of spine or weight-bearing joints, and
• Hepatic steatosis without prior evidence of active inflammation.

The Project overall error rate was 35 percent. This included claims recommended for denial due to providers not submitting the requested records and claims recommended for denial after review. Specific examples of insufficient documentation provided in the report included:

• Lack of documentation to support that the beneficiary had been previously unsuccessful with medical attempts (supervised dieting, exercise) at weight loss prior to surgical intervention,
• The submitted documentation did not include a signed operative report, and
• The submitted documentation did not include preoperative psychological evaluation with clearance for surgery and if treatable metabolic causes for obesity, such as adrenal or thyroid disorders, had been ruled out.

Recovery Auditors approved issue: Bariatric Surgery

Complex reviews for medical necessity of bariatric surgery is a current review issue for all four Recovery Audit Regions in the country. The approval date for this issue varies among the four Regions from November 2016 to February 1, 2017. Remember that the Recovery Audit look back period is three years. 

Office of Inspector General (OIG) Work Plan: Review of Medicare Payments for Bariatric Surgeries

In October 2017, the OIG added the Review of Medicare Payments for Bariatric Surgeries to their Active Work Plan Issues. As with the SMRC, the OIG referenced the CERT special study in the announcement. The OIG indicated that they will be reviewing “supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with Federal requirements.”

Next Step: Know the Coverage Requirements

While the new Fact Sheet references NCD 100.1 it does not reference additional guidance by the MACs. Do you know if your MAC has published additional guidance? The following table details the MACs that have published a Local Coverage Determination (LCD) or Coverage Article.  

As you can see, it is pretty clear why a Fact Sheet now and MMP, Inc. encourages you to become familiar with the NCD, any applicable MAC guidance, use the new Fact Sheet and Medicare Quarterly Compliance Newsletter as teaching tools and make sure your records support the medical necessity for the procedure.