ASMBS News and Update—August 2011

August 2011

by Robin L. Blackstone, MD, FACS, FASMBS

Dr. Blackstone is President of the American Society for Metabolic and Bariatric Surgery and Medical Director, Scottsdale Healthcare Bariatric Center, Scottsdale, Arizona.

ASMBS Mission Statement
The American Society for Metabolic and Bariatric Surgery was founded in 1983 to establish educational and support programs for surgeons and integrated health professionals. Our mission is to improve the care and treatment of people with obesity and related disease; to advance the science and understanding of metabolic surgery; to advocate for health care policy that ensures patient access to high-quality prevention and treatment of obesity. For more information, visit www. ASMBS.org. If you are interested in becoming a member or have questions about ASMBS, please contact Georgeann Mallory, the ASMBS Executive Director, via phone: (352)-331-4900 or e-mail: [email protected].

New Ruling from Centers for Medicare and Medicaid Services: Sleeve Gastrectomy ICD-9 Coding and DRG Mapping: Contributed by Jaime Ponce, President Elect ASMBS and Chair, Insurance Committee. The laparoscopic sleeve gastrectomy procedure (Current Procedural Terminology [CPT] code 43775) for the surgical treatment of obesity had an ICD-9 procedure code (43.89) that was not mapped to the obesity surgery Diagnosis Related Group (DRG) codes 619-621 when the patient diagnosis is morbid obesity (278.01). This diagnosis code was not assigned to any DRG, so as a default, the mapping automatically assigned an “unrelated” OR DRG (DRGs 981-983). This lack of appropriate DRG assignment was reflected in the MS-DRG software used by many hospitals and insurance companies. This issue created confusion and inappropriate coding or reimbursement issues with this procedure in some hospitals. In November 2010, the ASMBS requested CMS to address this issue and assign the appropriate obesity surgery DRGs 619-621 to the sleeve gastrectomy ICD-9 code (43.89).

CMS New Ruling: The Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (HIPPS) final rule display copy was published earlier this week with information about the revised ICD-9 codes for laparoscopic and open sleeve gastrectomy. Effective October 1, 2011, CMS will be assigning laparoscopic sleeve gastrectomy to ICD 43.82 and open sleeve gastrectomy to ICD 43.89. Both of these ICD-9 codes will be grouped to DRG 619, 620, and 621 (OR procedures for obesity).

It is important to note that laparoscopic sleeve gastrectomy remains a non-approved procedure by CMS National Coverage Determination. So, the procedure code 43.82 will be added to the “Noncovered Procedures” edit of the Medicare Code Editor (MCE). Because procedure code 43.89 includes several gastrectomy procedures, its inclusion in the MCE would be inappropriate. Therefore, it will not be placed on the MCE.
We expect the update on the MS-DRG software to be applied later this year and solve any confusion and inappropriate coding and reimbursement issues with this procedure. The ASMBS had a extended face-to-face meeting with Medicare about covering the sleeve in October 2010. We asked that it be covered since it was part of the BPD/DS which is covered. Medicare declined and stated that we would have to re-open the National Coverage Decision (NCD) to add the sleeve. The ASMBS Executive Council decided that in this political climate and with healthcare reform pending, that the CMS NCD represented a very important foundation in the national coverage landscape and could not be risked. Certainly, at some point in the not to distant future, sleeve, coverage for low BMI patients, and other important changes to the NCD will be brought forward by the ASMBS for consideration by Medicare.

American Association of Clinical Endocrinologists declare obesity as a disease in a statement approved on July 23, 2011. The ASMBS has adopted, as a part of the organizational mission statement, a policy that encourages collaborative relationships with our medical colleagues involved in the care and treatment of patients with obesity.

Increasingly, we are finding national medical societies are supportive and, in fact, share our mission. American Association for Clinical Endocrinologists (AACE) recently issued a new statement that obesity is a disease. This statement might mean it is a good time to contact your local endocrinologists and offer to give a presentation on how obesity and the metabolic syndrome responds to surgical therapy. Recently, in conjunction with Chris Still, MD, and the Geisinger Clinic, 42 primary care physicians (PCPs) attended a three-hour Category 1 Continuing Medical Education (CME) dinner meeting in Phoenix, Arizona, on July 28, 2011. Despite the heat and a long workday, attendance was strong and the attending physicians were intensely interested in the material. Having knowledgeable physician colleagues support patients in getting access to surgery is critical to changing the access equation.

To download Dr. Blackstone’s presentation to the Arizona PCP community on the ASMBS website in the Presidents Report section, visit http://bit.ly/geisingerPCPJuly282011.

To download the statement from AACE, visit http://images.aace.com/OnlineNews/images/ObesityAttachment.pdf.

ASMBS Executive Council votes to drop the requirement for angiographic arterial embolization for centers qualifying for ASMBS Bariatric Surgery Centers of Excellence. One of the goals of the ASMBS Quality/Standards Committee is to critically re-evaluate each of the Bariatric Surgery Center of Excellence (BSCOE) requirements and determine whether there is sufficient evidence to support each criterion. Requirement #4 refers to responsive critical care support and mandates that four consultants: anesthesia, endoscopist, interventional radiologist, and a critical care physician, be available onsite within 30 minutes. The interventional radiologist must be capable of performing inferior vena cava (IVC) filter placement, percutaneous drainage of intrabdominal abscesses, and angiographic arterial embolization. During the Rural Subcommittee Forum at the ASMBS Annual Meeting, many surgeons and program directors attended expressing frustration about having to provide angiographic capability that can cost up to two million dollars. The Rural subcommittee, led by Wayne English, MD, made this their first target for evaluation and, in an exhaustive literature search, could find no evidence for continuing this part of the requirement. Once they had completed their evaluation, they forwarded a letter to the Quality and Standards committee who concurred with their evaluation. The Executive Council confirmed the request at the monthly teleconference in July. The Surgical Review Corporation (SRC) has been notified and will begin working with the programs affected. It is a small start to the overall process of reviewing and renewing the standards in structure, process, and outcomes that programs have to meet to qualify for the ASMBS BSCOE program.

HealthGrades releases their ratings for 2011: Surgeons should take note of how their cases are being coded by their facility. HealthGrades recently released the HealthGrades 2011 Bariatric Surgery Trends in American Hospitals report (http://bit.ly/q17ubD). The goal of HealthGrades is to be a resource to patients in finding the best quality centers in their area. The report is based on data reported by selected facilities and their cases.

Have you ever stopped to consider, when you write down something in the medical record, how your facility reports it? Perhaps you did not even know that it is reported. When you start to think about it, when you write “anemia” or “atelectasis,” how is that coded by your facility? The answer is that it will be coded at the highest level allowable by what you write in the medical record so that the facility maximizes its revenue. The problem is, if you are not aware of how things are actually coded and therefore reported, inadvertent, routine postoperative patient issues may result in a “900”code. The 900 codes are publically reported as a complication and picked up by HealthGrades, CMS, and other rating systems.

Let me relate the experience of our own program in this regard. In the mid part of the last decade, the program at Scottsdale Healthcare, in which I have operated for 10 years, achieved a five-star rating with HealthGrades. The facility wanted to publish that fact but when they contacted HealthGrades, they were told they had to pay a high fee in order to publish this. The very next year, the program dropped to a three-star rating on HealthGrade, but our Institutional Review Board (IRB)-approved clinical database (which we keep on all patients; 99.9% of patients’ consent to participate) actually showed improved outcomes on Grades 2 and 3 complications in a high-volume program. Scottsdale Healthcare and the bariatric quality team began a process in 2009 where we audited every single chart of patients operated on (n=495) in either the inpatient or outpatient setting during that calendar year to determine whether there was a problem with how our cases were being reported. In addition, we audited all patients for 90 days after the primary surgery to determine if they had any additional encounters with the system, and all records were reviewed and compared to what had been coded by the facility. We found that our facility reported a higher incidence of complications than the reconciled report supported due to duplication and inaccurate coding. Unreconciled public reporting had an error rate of over reporting of 19.3 percent and the median charge for each utilization event was $41,096.[1] The review of the medical record also found that surgeons and mid-level providers did not understand the consequences of using certain words to describe postoperative events (e.g., atelectasis is coded as “pulmonary collapse”) or the need to clarify in the medical chart whether or not this was a normal and expected patient issue after surgery. In addition, they failed to identify when a problem existed at the time of the admission (e.g., the patient who has a history of coronary artery disease [CAD] and previous myocardial infarction [MI], or cellulitis of the lower extremities on admission). This project led to a constant and ongoing reconciliation process between the bariatric coordinator and quality/coding facility staff to make sure all charges and public reporting are reconciled to an accurate clinical record. I encourage each program to undergo evaluation to determine how your charts are being coded and make sure that you are not providing the words and phrases that lead to inaccurate coding.

For a copy of the poster presentation, which gives the details of the process used for reconciliation, visit: http://bit.ly/accuracyInPublic
Reporting

The ASMBS evaluated the HealthGrades report and methodology published and found that it has a number of limitations. The ASMBS has written to HealthGrades to express our concerns about their methodology and statements. In 2004/2005 the ASMBS formed the BSCOE and the American College of Surgeons (ACS) formed the Bariatric Surgery Center Network (BSCN). Both programs were designed to improve the quality of care in bariatric surgery. The designation process involves site visited and affirmed implementation of structure, processes, and measurement of outcomes using the Bariatric Outcomes Longitudinal Database (BOLD) or National Surgical Quality Improvement Program (NSQIP). The ASMBS believes that patients interested in bariatric surgery should visit one of the many ASMBS- or ACS-accredited centers around the nation rather than relying on HealthGrades’ selected centers. As we improve our patient portal on the ASMBS website, we should be able to help the public find COEs.

For more information about the response of the ASMBS to HealthGrades please go to: http://bit.ly/pz5dKK.

Pediatric guidelines statement approved by the Executive Council. The ASMBS Pediatric Committee, led by Marc Michalsky, MD, and Kirk Reichard, MD, developed the Adolescent Bariatric Surgery Best Practice Guidelines. The Guidelines document was approved by the Executive Council after a long and thorough process of vetting, including public comment by the membership of ASMBS.

Dr. Michalsky provided the following introduction to the guidelines: Recent evidence, including data from the National Association of Children’s Hospitals and Related Institutions (NACHRI), have shown that the number of tertiary care centers in the United States offering multidisciplinary assessment and treatment strategies designed to combat severe obesity in the child population, including bariatric surgery, has risen steadily over the past decade. In response to the mounting body of evidence demonstrating the link between severe childhood obesity and the increased risk of development and progression of multiple associated comorbidities, as well as the data demonstrating the amelioration of many comorbid disease, states following surgically induced weight loss, the ASMBS Pediatric Committee has been granted approval from the ASMBS Executive Council for the general dissemination of a structured best-practice guideline. The recently approved guidelines, which represent a modification and update of the authoritative literature review and deliberation assembled by the Betsy Lehman Center for Patient Safety and Medical Error Reduction[2] are designed to serve as a fundimental series of recommendations regarding the development and implementation of a focused adolescent bariatric surgery program. In addition to a brief review of the most commonly encountered comorbid diseases observed in the adolescent population with severe obesity, the authors present current recommendations pertaining to adolescent bariatric surgery team member qualifications, a review of adolescent-specific risks and outcomes following surgically induced weight loss, informed surgical consent, as well as an evidenced-based review of specific bariatric procedures used to achieve weight loss in this emerging surgical population.

You can get a copy of Adolescent Bariatric Surgery Best Practice Guideline on the ASMBS website at: http://bit.ly/qQ4u7V

Insurance Committee/Preoperative Weight Loss Requirement. The requirement that patients should go through an arbitrary medical weight loss period prior to being able to access surgical therapy for obesity is a significant deterrent to patients seeking surgery. Usually required by the insurance plan, some programs estimate that over one-third of patients will be unable to comply with this requirement and drop out of the process to qualify for surgery.

The ASMBS issued an evidence-based position statement on preoperative supervised weight loss requirements.[3] In an effort to communicate our position to the insurance payer community, the ASMBS Insurance Committee, led by Jaime Ponce, has sent a letter with a copy of the statement to the Medical Directors of the major health plans.

If you have insurance plans in your area that are still using the six-month medical weight loss requirement in their plans, please send a letter listing the Medical Directors name, mailing address, and e-mail address (if available) to Nooriel Nolan ([email protected]). We will then will send a letter to the medical director with a copy of the letter and the ASMBS position statement on ASMBS stationary.
To view a copy of the letter with references, please visit: http://bit.ly/pEAgrA

North Carolina Medicaid announces plan to reinstate Bariatric surgery coverage. After eliminating bariatric surgery coverage last year as part of budget cuts, the state of North Carolina has announced its plan to reinstate bariatric surgery coverage in the immediate future. The reinstatement will require that all procedures are performed at an ASMBS COE. Special thanks to all of the North Carolina surgeons, especially Dr. Walter Pories, the North Carolina Chapter of ASMBS, as well as our industry friends who dedicated significant time, effort, and political capital to secure the reinstatement.

Bariatric surgery benefits are threatened in Iowa—ASMBS Access to Care Committee and OAC fight for reversal. Iowa, in the midst of financial difficulty, moved to strike the support for obesity surgery for Medicaid recipients. The ASMBS Access to Care Committee mobilized the Rapid Response team and Iowa has decided to keep the Benefit in place. The role of surgeon-entered data in BOLD was critical in the reversal of this action. In July 2011, Joe Nadglowski, President/CEO of the Obesity Action Coalition (OAC) notified the ASMBS Access to Care Committee, led by John Morton, MD, that Iowa was considering dropping their support of bariatric surgery in the Medicaid program. The ASMBS Access to Care Rapid Response Team was activated. This team is assembled with surgeons from the state, industry colleagues as well as the OAC and Access to Care Committee members.

For the past three years, any time that bariatric surgery benefits are threatened, the rapid response team is activated to respond to the threat and attempt to reverse it. The best method for combating the specific threat is identified and the effort is led and coordinated by the Rapid Response Team and Chair of the Access Committee. Over the last few years an invaluable part of our response included the data in BOLD that surgeons have entered. Debbie Winegar, Vice President of Data at the SRC, has been a strong ally. She and her team have worked to provide us with the data that we need to push back against this threat. Dr. Morton wrote a terrific letter to Governor Branstad in Iowa responding to specific issues in Iowa. One of the most persuasive parts of the letter has to do with cost effectiveness of bariatric surgery.

To access the entire letter, please visit http://s3.amazonaws.com/publicASMBS/top5/august2011/Governor%20Terry%20Branstad%20%20Iowa%20Medicaid%20Letter.pdf

References
1. Accuracy in public reporting of healthcare utilization and adverse events in community hospital. Presented at: The American Society for Metabolic and Bariatric Surgery Annual Meeting; June 12–17, 2011, Orlando, Florida.
2. Pratt JS, Lenders CM, Dionne EA, et al. Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring). 2009;17(5):901–910
3. Brethauer S. ASMBS Position Statement on Preoperative Supervised Weight Loss Requirements. Surg Obes Relat Dis. 2011;7(3):257–260.

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Category: ASMBS News and Update, Past Articles