Insurance Update: CMS APC – November 2012

Over the course of this year the insurance committee has been involved in the outpatient positioning and payment, by CMS, of Adjustable Gastric Band.  While it is clear that outpatient adjustable gastric banding is a viable option, clinical guidelines on appropriateness of the outpatient setting and appropriate payment were lacking.  We have previously reported that CMS has placed a hold on the RAC auditors to request charts on Adjustable gastric banding for the time being.  This should reassure hospitals that gastric banding can be performed in the appropriate setting without fear of RAC audit.

Today we are happy to announce CMS has decided to move the outpatient facility adjustable gastric banding to a higher paying APC from 0131 ($3,497) to 0132 ($5,268) for FY2013.  While this amount is still below the Medicare reported median cost of $6782, it is much closer and more accurately reflects the costs of the procedure.  CMS initially assigned Adjustable Gastric Banding to the same APC 0131 following this years review meeting.  However, upon input from several commenters, including Doctors Morton and Brengman from ASMBS, the procedure was viewed as being more similar technically and in resource use to procedures from APC 0132.

ASMBS considers this APC reassignment by CMS as a step in the right direction and enough movement in the reimbursement to allow outpatient Adjustable gastric band to be performed more widely.  As a greater number of procedures are performed in the outpatient setting, a larger cost database will be developed.  This database will allow the ASMBS and others to seek reimbursement at or near 100% median cost based on actual cost data.

Here is the link to the final rule.  See pages 433-436.


Matt Brengman, MD, Chair, Insurance Committee


ASMBS Insurance Committee Disclaimer:

The coding, billing and reimbursement of any medical treatment or procedure is highly subjective, and is dependent upon the interpretation of multiple variables, to include differing Medicare fiscal agent Local Coverage Determinations, and a wide variety of commercial insurance payers’ policies. American Society for Metabolic and Bariatric Surgery (ASMBS) presents the information in this guide only as general information and a point of reference. ASMBS does not and cannot guarantee or warranty that the reliance upon any information presented in this guide will result in any provider’s compliance with a particular payer’s coding, billing or reimbursement requirements. This guide does not and cannot constitute professional advice or be a substitute for applicable professional advice regarding the coding, billing or reimbursement for any specific circumstance. ASMBS highly recommends that every provider consult a coding, billing or reimbursement professional regarding the submission of any specific claim for reimbursement.

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