Posted 4/2/2013

The Insurance Committee has become aware of a Laparoscopic Sleeve Gastrectomy issue with some private payors. The issue is somewhat complex but we’ll try to explain it here.

When the CPT Code for Laparoscopic Sleeve Gastrectomy (43775) was created by the CPT committee it was valued as all new codes are. This value is slightly modified each year. Below are the most recent valuations:

Year National Average Medicare Payment Conversion Factor RVU’s (Calculated)
2012 $1,285 $34.0376 37.75
2011 $1,299 $33.9764 38.23
2010 $1,293 $36.0846 35.83
Source: Medicare Physician Fee Schedule

This value is published quarterly by CMS in the Medicare Physician Fee Schedule. Many Private Payors use these values to calculate physician reimbursement.

When CMS decided that coverage for sleeve gastrectomy would be a local determination. The procedure also became locally priced. Through our research it appears this is the standard for locally determined procedures. The convention for locally priced procedures is a zero value in the CMS physician fee schedule. Unfortunately, This has led some private payors to now value the sleeve gastrectomy code as zero RVU’s. This is likely an automated problem. With payment software pulled the new value directly from the fee schedule.

The insurance committee is working with our industry partners to have the valuation restored to the Physician Fee Schedule. At the same time we are interested in several pieces of information from our members.

  1. Are you having payment issues with Sleeve gastrectomy through private payors?
  2. Who are these payors?
  3. Have you received payment from your local CMS contractor for Laparoscopic sleeve gastrectomy?

Please help us work through this important issue and send your responses to: insurance@asmbs.org.

Matthew Brengman, MD
Insurance Committee, Chair 

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.