Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2816 Date: November 15, 2013

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1 S anual System Pub edicare laims Processing Department of ealth & uman Services (DS) enters for edicare & edicaid Services (S) Transmittal 2816 Date: November 15, 2013 hange equest 8484 SUBJET: Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity. SUAY OF ANGES: Effective for dates of service on and after September 24, 2013, facility certification shall no longer be required for coverage of covered bariatric surgery procedures. EFFETVE DATE: September 24, 2013 PLEENTATON DATE: December 17, 2013 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. ANGES N ANUAL NSTUTONS: (N/A if manual is not updated) =EVSED, N=NEW, D=DELETED-Only One Per ow. /N/D APTE / SETON / SUBSETON / TTLE 32/150.1/Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity 32/150.3/D Procedure odes for Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity (A/As only) 32/150.4/D Diagnosis odes for Bariatric Surgery 32/150.5/D Diagnosis odes for B 35 32/150.6/laims Guidance for Payment 32/150.8/B/A Billing equirements. FUNDNG: For Fiscal ntermediaries (Fs), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by S; ontractors activities are to be carried out with their operating budgets For edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. S does not construe this as a change to the A statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

2 V. ATTAENTS: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 Attachment - Business equirements Pub Transmittal: 2816 Date: November 15, 2013 hange equest: 8484 SUBJET: Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity EFFETVE DATE: September 24, 2013 PLEENTATON DATE: December 17, GENEAL NFOATON A. Background: This change request is due to a reconsideration of section of the National overage Determination (ND) anual titled Bariatric Surgery for Treatment of orbid Obesity. On January 24, 2013 the enters for edicare & edicaid Services (S) initiated a national coverage analysis (NA) for the reconsideration of the requirement that covered bariatric surgery procedures are only covered when performed in facilities that are certified. n addition, we decided to the make the some additional changes to the ND which are defined in section B. n 2006, S established a National overage Determination (ND) on Bariatric Surgery for the Treatment of orbid Obesity (ND anual Section 100.1).For edicare beneficiaries who have a B 35, have at least one co-morbidity related to obesity, and who have been previously unsuccessful with medical treatment for obesity, the following procedures were determined to be reasonable and necessary: open and laparoscopic oux-en-y gastric bypass (YGBP); laparoscopic adjustable gastric banding (LAGB); and, open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GDS). n addition, the ND stipulates that these bariatric procedures are covered only when performed at facilities that are: (1) certified by the American ollege of Surgeons (AS) as a Level 1 Bariatric Surgery enter or (2) certified by the American Society for Bariatric Surgery (ASBS) as a Bariatric Surgery enter of Excellence (BSOE) (Program Standards and requirements in effect on February 15, 2006).The 2006 ND specifically non-covered open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, and open adjustable gastric banding because there was a paucity of evidence to support claims of improved health outcomes from those procedures. This NA specifically addressed the need for the continuation of the requirement for facility certification by AS or the AABS) currently the American Society for etabolic and Bariatric Surgery (ASBS). B. Policy: The S has determined that the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for edicare beneficiaries. Therefore, S removed this certification requirement. S has determined that no changes be made to the bariatric surgery procedures that are deemed covered in section of the National overage Determination (ND) anual. S changed the title to better reflect the scope of the ND and to make it clear in the manual that under the existing policy the local edicare Administrative ontractors have the authority to make coverage decisions for any bariatric surgery procedures not specifically identified as covered or non-covered by an ND.

4 n addition, to the proposed decision above, S is renumbering and consolidating its manual for section This is an administrative change only to make it easier for the public to read and understand the ND manual. There is no change in coverage because of the renumbering and consolidation. The additional NDs related to bariatric surgery are consolidated and subsumed into section of the ND anual. These include sections 40.5, 100.8, and BUSNESS EQUEENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number equirement esponsibility A/B A Effective for dates of service on and after September 24, 2013, contractors shall remove any edits that require certified facility requirements for claims for Bariatric Surgery for Treatment of o- orbid onditions elated to orbid Obesity. A B X X D E A F A E Shared- System aintainers F S S S V S W F Other ontractors shall make note of the new title and change in requirement noted in Publication , hapter 32, Section Effective for bariatric surgery for treatment of comorbid conditions related to morbid obestity claims with dates of service on and after August 24, 2013, contractors shall not search for claims, but shall adjust any claims processed inappropriately as a result of this if brought to their attention. X X X X. POVDE EDUATON TABLE Number equirement esponsibility LN Article : A provider education article related to this instruction will be available at Education/edicare-Learning-Network- LN/LNattersArticles/ shortly after the A/B A A B X X D E A F A E Other

5 Number equirement esponsibility is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in the contractor s next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. A/B A A B D E A F A E Other V. SUPPOTNG NFOATON Section A: ecommendations and supporting information associated with listed requirements: N/A "Should" denotes a recommendation. X-ef equirement Number ecommendations or other supporting information: Section B: All other recommendations and supporting information: N/A V. ONTATS Pre-mplementation ontact(s): chanelle jones, or chanelle.jones@cms.hhs.gov (Practitioner Part B), Deirdre O'onnor, or Deirdre.Oconnor@cms.hhs.gov (overage), Patricia Brocato-Simons, or patricia.brocatosimons@cms.hhs.gov (overage), Wanda Belle, or wanda.belle@cms.hhs.gov (coverage), Yvette ousar, or yvette.cousar@cms.hhs.gov (Practitioner Part B), Shauntari heely, or shauntari.cheely@cms.hhs.gov (nstitutional laims) Post-mplementation ontact(s): ontact your ontracting Officer's epresentative (O) or ontractor anager, as applicable. V. FUNDNG Section A: For Fiscal ntermediaries (Fs), egional ome ealth ntermediaries (s), and/or arriers:

6 No additional funding will be provided by S; ontractors activities are to be carried out with their operating budgets Section B: For edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. S do not construe this as a change to the A Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

7 edicare laims Processing anual hapter 32 Billing equirements for Special Services General (ev.2816, ssued: , Effective: , mplementation: ) Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity Effective for services on or after February 21, 2006, edicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (B) 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. n addition, the procedure must be performed at an approved facility. A list of approved facilities may be found at Surgery.html Effective for dates of service on and after September 24, 2013, the enters for edicare & edicaid Services (S) has removed the certified facility requirements for Bariatric Surgery for Treatment of o- orbid onditions elated to orbid Obesity. Please note the additional national coverage determinations related to bariatric surgery will be consolidated and subsumed into Publication , hapter 1, section These include sections 40.5, 100.8, and Open oux-en-y gastric bypass (YGBP) Laparoscopic oux-en-y gastric bypass (YGBP) Laparoscopic adjustable gastric banding (LAGB) Open biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GDS) Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GDS) Laparoscopic sleeve gastrectomy (LSG) (Effective June 27, 2012, covered at edicare Administrative ontractor s (As) discretion) D Procedure odes for Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity (A/As only) (ev.2816, ssued: , Effective: , mplementation: ) overed D Procedure odes For services on or after February 21, 2006, the following independent D-9/D-10 procedure codes are covered for bariatric surgery: Laparoscopic gastroenterostomy (laparoscopic oux-en-y), or Bypass Stomach to Duodenum with Autologous Tissue Substitute, 0D16479 Bypass Stomach to Jejunum with Autologous Tissue Substitute, 0D1647A Bypass Stomach to leum with Autologous Tissue Substitute, 0D1647B Bypass Stomach to Transverse olon with Autologous Tissue Substitute, 0D1647L Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous 0D164J9 Endoscopic Approach

8 0D164JA 0D164JB 0D164JL 0D164K9 0D164KA 0D164KB 0D164KL 0D164Z9 0D164ZA 0D164ZB 0D164ZL Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach Bypass Stomach to leum with Synthetic Substitute, Percutaneous Endoscopic Approach Bypass Stomach to Transverse olon with Synthetic Substitute, Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Bypass Stomach to leum with Non-autologous Tissue Substitute, Bypass Stomach to Transverse olon with Non-autologous Tissue Substitute, Bypass Stomach to Duodenum, Bypass Stomach to Jejunum, Bypass Stomach to leum, Bypass Stomach to Transverse olon, Percutaneous Endoscopic Approach Other gastroenterostomy (open oux-en-y), or Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open 0D16079 Approach Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open 0D1607A Approach Bypass Stomach to leum with Autologous Tissue Substitute, Open 0D1607B Approach Bypass Stomach to Transverse olon with Autologous Tissue Substitute, 0D1607L Open Approach 0D160J9 Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach 0D160JA Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach 0D160JB Bypass Stomach to leum with Synthetic Substitute, Open Approach Bypass Stomach to Transverse olon with Synthetic Substitute, Open 0D160JL Approach Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, 0D160K9 Open Approach Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Open 0D160KA Approach Bypass Stomach to leum with Non-autologous Tissue Substitute, Open 0D160KB Approach Bypass Stomach to Transverse olon with Non-autologous Tissue 0D160KL Substitute, Open Approach 0D160Z9 Bypass Stomach to Duodenum, Open Approach 0D160ZA Bypass Stomach to Jejunum, Open Approach 0D160ZB Bypass Stomach to leum, Open Approach 0D160ZL Bypass Stomach to Transverse olon, Open Approach Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via 0D16879 Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via 0D1687A Bypass Stomach to leum with Autologous Tissue Substitute, Via Natural 0D1687B or Artificial Opening Endoscopic Bypass Stomach to Transverse olon with Autologous Tissue Substitute, 0D1687L Via

9 0D168J9 0D168JA 0D168JB 0D168JL 0D168K9 0D168KA 0D168KB 0D168KL 0D168Z9 0D168ZA 0D168ZB 0D168ZL Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to leum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Transverse olon with Synthetic Substitute, Via Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Via Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Via Bypass Stomach to leum with Non-autologous Tissue Substitute, Via Bypass Stomach to Transverse olon with Non-autologous Tissue Substitute, Via Bypass Stomach to Duodenum, Via Natural or Artificial Opening Endoscopic Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic Bypass Stomach to leum, Via Bypass Stomach to Transverse olon, Via Natural or Artificial Opening Endoscopic Laparoscopic gastric restrictive procedure (laparoscopic adjustable gastric band and port insertion), or 0DV64Z estriction of Stomach with Extraluminal Device, To describe either laparoscopic or open BPD with DS or GDS, one code from each of the following three groups must be on the claim: Group 1: Open and other partial gastrectomy, or 0DB60Z3 Excision of Stomach, Open Approach, Vertical 0DB60ZZ Excision of Stomach, Open Approach 0DB63Z3 Excision of Stomach, Percutaneous Approach, Vertical 0DB63ZZ Excision of Stomach, Percutaneous Approach 0DB67Z3 Excision of Stomach, Via Natural or Artificial Opening, Vertical 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening Excision of Stomach, Via, 0DB68Z3 Vertical Group 2: solation of segment of small intestine (Note: translates to a cluster in D-10: One code from A- below is required for a correct equivalent), or 0DB80ZZ Excision of Small ntestine, Open Approach - A 0DB90ZZ Excision of Duodenum, Open Approach - A 0DBB0ZZ Excision of leum, Open Approach - A 0D160ZB Bypass Stomach to leum, Open Approach - B 0F190Z3 Bypass ommon Bile Duct to Duodenum, Open Approach - Group 3: Small-to-small intestinal anastomosis or Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Open 0D19079 Approach Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Open 0D1907A Approach Bypass Duodenum to leum with Autologous Tissue Substitute, Open 0D1907B Approach Bypass Duodenum to Duodenum with Synthetic Substitute, Open 0D190J9 Approach

10 0D190JA 0D190JB 0D190K9 0D190KA 0D190KB 0D190Z9 0D190ZA 0D190ZB 0D D1947A 0D1947B 0D194J9 0D194JA 0D194JB 0D194K9 0D194KA 0D194KB 0D194Z9 0D194ZA 0D194ZB 0D D1987A 0D1987B 0D198J9 0D198JA 0D198JB 0D198K9 0D198KA 0D198KB 0D198Z9 0D198ZA 0D198ZB Bypass Duodenum to Jejunum with Synthetic Substitute, Open Approach Bypass Duodenum to leum with Synthetic Substitute, Open Approach Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Open Approach Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Open Approach Bypass Duodenum to leum with Non-autologous Tissue Substitute, Open Approach Bypass Duodenum to Duodenum, Open Approach Bypass Duodenum to Jejunum, Open Approach Bypass Duodenum to leum, Open Approach Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Bypass Duodenum to leum with Autologous Tissue Substitute, Bypass Duodenum to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Approach Bypass Duodenum to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach Bypass Duodenum to leum with Synthetic Substitute, Percutaneous Endoscopic Approach Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Bypass Duodenum to leum with Non-autologous Tissue Substitute, Bypass Duodenum to Duodenum, Bypass Duodenum to Jejunum, Bypass Duodenum to leum, Bypass Duodenum to Duodenum with Autologous Tissue Substitute, Via Bypass Duodenum to Jejunum with Autologous Tissue Substitute, Via Bypass Duodenum to leum with Autologous Tissue Substitute, Via Bypass Duodenum to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Duodenum to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Duodenum to leum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Bypass Duodenum to Duodenum with Non-autologous Tissue Substitute, Via Bypass Duodenum to Jejunum with Non-autologous Tissue Substitute, Via Bypass Duodenum to leum with Non-autologous Tissue Substitute, Via Bypass Duodenum to Duodenum, Via Natural or Artificial Opening Endoscopic Bypass Duodenum to Jejunum, Via Natural or Artificial Opening Endoscopic Bypass Duodenum to leum, Via

11 Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Open 0D1A07A Approach Bypass Jejunum to leum with Autologous Tissue Substitute, Open 0D1A07B Approach 0D1A0JA Bypass Jejunum to Jejunum with Synthetic Substitute, Open Approach 0D1A0JB Bypass Jejunum to leum with Synthetic Substitute, Open Approach Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Open 0D1A0KA Approach Bypass Jejunum to leum with Non-autologous Tissue Substitute, Open 0D1A0KB Approach 0D1A0ZA Bypass Jejunum to Jejunum, Open Approach 0D1A0ZB Bypass Jejunum to leum, Open Approach Bypass Jejunum to Jejunum with Autologous Tissue Substitute, 0D1A47A Bypass Jejunum to leum with Autologous Tissue Substitute, Percutaneous 0D1A47B Endoscopic Approach Bypass Jejunum to Jejunum with Synthetic Substitute, Percutaneous 0D1A4JA Endoscopic Approach Bypass Jejunum to leum with Synthetic Substitute, Percutaneous 0D1A4JB Endoscopic Approach Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, 0D1A4KA Bypass Jejunum to leum with Non-autologous Tissue Substitute, 0D1A4KB 0D1A4ZA Bypass Jejunum to Jejunum, 0D1A4ZB Bypass Jejunum to leum, Bypass Jejunum to Jejunum with Autologous Tissue Substitute, Via 0D1A87A Bypass Jejunum to leum with Autologous Tissue Substitute, Via Natural 0D1A87B or Artificial Opening Endoscopic Bypass Jejunum to Jejunum with Synthetic Substitute, Via Natural or 0D1A8JA Artificial Opening Endoscopic Bypass Jejunum to leum with Synthetic Substitute, Via Natural or 0D1A8JB Artificial Opening Endoscopic Bypass Jejunum to Jejunum with Non-autologous Tissue Substitute, Via 0D1A8KA Bypass Jejunum to leum with Non-autologous Tissue Substitute, Via 0D1A8KB 0D1A8ZA Bypass Jejunum to Jejunum, Via 0D1A8ZB Bypass Jejunum to leum, Via 0D1A8Z Bypass Jejunum to ecum, Via 0D1B07B Bypass leum to leum with Autologous Tissue Substitute, Open Approach 0D1B0JB Bypass leum to leum with Synthetic Substitute, Open Approach Bypass leum to leum with Non-autologous Tissue Substitute, Open 0D1B0KB Approach 0D1B0ZB Bypass leum to leum, Open Approach Bypass leum to leum with Autologous Tissue Substitute, Percutaneous 0D1B47B Endoscopic Approach Bypass leum to leum with Synthetic Substitute, Percutaneous Endoscopic 0D1B4JB Approach Bypass leum to leum with Non-autologous Tissue Substitute, 0D1B4KB 0D1B4ZB Bypass leum to leum, Bypass leum to leum with Autologous Tissue Substitute, Via Natural or 0D1B87B Artificial Opening Endoscopic

12 Bypass leum to leum with Synthetic Substitute, Via Natural or Artificial 0D1B8JB Opening Endoscopic Bypass leum to leum with Non-autologous Tissue Substitute, Via Natural 0D1B8KB or Artificial Opening Endoscopic 0D1B8ZB Bypass leum to leum, Via 0D1B8Z Bypass leum to ecum, Via NOTE: There is no distinction between open and laparoscopic BPD with DS or GDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered. Effective June 27, 2012, the following D-9/D-10 procedure code is covered for bariatric surgery: Laparoscopic sleeve gastrectomy/0db64z3 Excision of stomach, percutaneous endoscopic approach, vertical, is covered at contractor s discretion D Diagnosis odes for Bariatric Surgery (ev.2816, ssued: , Effective: , mplementation: ) For services on or after February 21, 2006, the following D-9/D-10 diagnosis code is covered for bariatric surgery if certain other conditions are met: orbid obesity; severe obesity/e orbid (severe) obesity due to excess calories D Diagnosis odes for B 35 (ev.2816, ssued: , Effective: , mplementation: ) The following D-9 diagnosis codes identify B 35: V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex , adult V Body ass ndex 70.0 and over, adult The following D-10 diagnosis codes identify B 35: Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex , adult

13 Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex , adult Z Body ass ndex 70.0 and over, adult laims Guidance for Payment (ev.2816, ssued: , Effective: , mplementation: ) overed Bariatric Surgery Procedures for Treatment of o-orbid onditions elated to orbid Obesity ontractors shall process covered bariatric surgery claims as follows: 1. dentify bariatric surgery claims. ontractors identify inpatient bariatric surgery claims by the presence of D-9/D-10 diagnosis code /E66.01as the primary diagnosis (for morbid obesity) and one of the covered D-9/D-10 procedure codes listed in ontractors identify practitioner bariatric surgery claims by the presence of D-9/D-10 diagnosis code /E66.01 as the primary diagnosis (for morbid obesity) and one of the covered PS procedure codes listed in Perform facility certification validation for all bariatric surgery claims on a pre-pay basis up to and including date of service September 23, A list of approved facilities are found at the link noted in section 150.1, section A, above. 3. eview bariatric surgery claims data and determine whether a pre- or post-pay sample of bariatric surgery claims need further review to assure that the beneficiary has a B 35 (V85.35-V85.45/Z68.35-Z68.45) (see D-10 equivalents above in section 150.5), and at least one co-morbidity related to obesity The A/B A medical director may define the appropriate method for addressing the obesity-related comorbid requirement. Effective for dates of service on and after September 24, 2013, S has removed the certified facility requirements for Bariatric Surgery for Treatment of o-orbid onditions elated to orbid Obesity. NOTE: f D-9/D-10 diagnosis code /E66.01 is present, but a covered procedure code (listed in or 150.3) is/are not present, the claim is not for bariatric surgery and should be processed under normal procedures B/A Billing equirements (ev.2816, ssued: , Effective: , mplementation: ) The B/A will pay for bariatric surgery only when the services are submitted on the following type of bill (TOB): 11X. Type of facility and setting determines the basis of payment: For services performed in ndian ealth Services inpatient hospitals, TOB 11X under the inpatient prospective payment system (PPS) is based on the diagnosis-related group (DG). For services performed in inpatient hospitals, TOB 11X under PPS is based on the DG. For services performed in S critical access hospitals (As), TOB 11X, payment is based on 101% facility specific per diem rate. For services performed in A inpatient hospitals, TOB 11X, payment is based on 101% of reasonable cost.

Transmittal 2127 Date: DECEMBER 29, 2010

Transmittal 2127 Date: DECEMBER 29, 2010 anual ystem Pub 100-04 edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2127 Date: DEEBE 29, 2010 hange equest 7262 UBJET: edical Nutrition