2021 BILLING AND CODING GUIDE SADI-S Physician Guide for ...

2021 BILLING AND CODING GUIDE

SADI-S Physician Guide for Unlisted Procedure Codes

SADI-S (Single Anastomosis Duodenal Switch) is a procedure for morbid obesity based on the biliopancreatic diversion in which a sleeve gastrectomy is followed by an end-to-side duodeno-ileal diversion. The single anastomosis duodenal switch works by creating a sleeve gastrectomy where the stomach is reduced and narrowed like a tube for restriction and hunger control. In the second step, the intestines are rerouted similar to a gastric bypass to reduce the surface for food absorption. Specifically, the middle part of the small bowel is excluded from food transit. After this procedure, the food travels from the small new stomach to the distal intestine bypassing a long segment of the small bowel, which remains in the abdominal cavity, but is excluded from the food circulation. These anatomical changes decrease oral intake and reduce the absorption of the nutrients and calories consumed.1

CPT?2 does not currently assign a code for this procedure. The CPT? Manual requires that clinicians "[s]elect the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code." Unlisted codes are available within each section of the CPT manual for when a specific code to describe the procedure is not available. Use of an unlisted code is not uncommon for new types of procedures. This guide will provide instruction for reporting the SADI-S procedure. For information related to hospital ICD-10-PCS coding and related DRGs please review the Medtronic guide for Bariatric Surgery found at .

SADI-S is typically an inpatient procedure. HCPCS3 codes are not used for hospital inpatient claims. For use in the outpatient setting there is not a recommended HCPCS code.

What is the CPT? code used to report the physician work associated with SADI-S?

Physicians will report the appropriate unlisted CPT procedure code for their professional service associated with the surgery. Providers are encouraged to review relevant medical policy on the topic of Bariatric Surgery as some commercial payers have included guidance related to the use of either 439994 or 436595.

CPT CODE

43999 43659

DESCRIPTION

Unlisted procedure, stomach Unlisted laparoscopy procedure, stomach

2021 MEDICARE PHYSICIAN FACILITY FEE SCHEDULE6

Carrier priced

Carrier priced

What is the RVU assignment for an unlisted procedure code?

Relative value units (RVUs) are not assigned to unlisted codes because the codes do not identify usual procedural components, or the effort/skill required for the service. When using an unlisted code, it is necessary to provide specific information regarding the procedure(s) identified by the code (i.e., operative note, office notes). The supporting documentation should include an adequate definition or description of the nature, extent and need for the procedure or service, as well as the time, effort, and equipment necessary to provide the service.7 Payers will then use this information for assignment of a fee.

How is payment determined if there is no RVU assignment?

Unlisted procedures are typically manually priced since they are used to report a variety of procedures without a dedicated code. The provider must submit documentation as to the work completed. A comparable code may be suggested that has a similar approach or anatomic site, and/or requires a comparable about of clinical expertise or time.

As payment is assigned based on a review of the submitted information expect delays in processing of the claim beyond the regular time expected. Allow time for appeal if the initial claim is denied.

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Is a modifier 26 (Professional Services) necessary for reporting the inpatient procedure?

No, it is not appropriate to append any modifier to an unlisted code because modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code. Unlisted codes do not describe a specific service; therefore, it is not necessary to utilize modifiers.8

Is SADI-S covered by insurance?

Providers are encouraged to verify coverage and benefits prior to providing care. Some payers may address coverage for SADI-S within their policies for Bariatric Surgery. For assistance with understanding the coverage in your area please contact the Medtronic Minimally Invasive Therapy Group Reimbursement Support Program at 877-278-7482 or Rs.MedtronicMITGReimbursement@.

If the payer requires the use of another code can this be reported rather than the unlisted CPT?

Some payers have chosen to address SADI-S within their bariatric procedure policies and direct the use of alternate CPT codes, and in some cases existing codes that describe other procedures. Providers are encouraged to review member coverage and only use alternate coding when expressly required by the payer. When no such guidance exists the use of the unlisted CPT is recommended.

Can unlisted procedure codes be pre-authorized?

Pre-authorization options vary by payer. Medicare Fee for Service (FFS) does not allow for pre-authorization for bariatric procedures. If reporting the unlisted procedure code to Medicare FFS coverage will be determined based on a review of documentation and assessment of medical necessity when the claim is submitted. As discussed above providers should be prepared to document the work provided associated with the surgery as this is used for rate assignment. Commercial payers have various processes for authorization of unlisted codes. Providers are encouraged to check with the individual insurance carrier to determine the requirement for each patient. Generally, pre-authorization is allowed as the service is not defined by the CPT or RVU. Providers may wish to submit a Letter of Medical Necessity (LMN) which outlines the following key metrics:

Clinic notes to support medical necessity of the procedure Operative note providing the nature and extent of the patient condition and detailing the work involved in the

procedure Published articles and clinical information supporting the efficacy of the procedure Cover letter that is concise and outlines the procedure, medical necessity, and fee with supporting justification.

(Sample Letter below; must be modified by the provider before submission)

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Sample Letter of Medical Necessity (LMN)

An editable template can be provided for use when requesting coverage for an unlisted procedure. Providers must customize to include information related to the specific surgery, diagnosis(s), and medically necessary reason for the request. Please contact the Medtronic MITG Reimbursement Support Program at 877-278-7482 or Rs.MedtronicMITGReimbursement@ for a copy of this document.

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1 2CPT copyright 2020 American Medical Association. All rights reserved. CPT? is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein 3Centers for Medicare & Medicaid Services. Alpha-numeric HCPCS. 4 ry.pdf 5 6Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID-19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID-19; Final Rule, Federal Register (85 Fed. Reg. No. 248 84472- 85377) 42 CFR Parts 400, 410, 414, 415, 423, 424, and 425. 7CPT Assistant December 2012 and CPT Assistant November 2010 8CPT Assistant August 2002

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