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Reporting Death or Complications from Morbid Obesity Surgeries
1. Which surgeries do I report?
Was the procedure performed one of the following procedures?
Current Procedural Terminology (CPT) Codes:
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en Y gastroenterostomy (roux limb 150 cm or less)
43645 Laparoscopic, gastric restrictive surgery, with gastric bypass and Roux-en Y gastroenterostomy (roux limb 150 cm or less) with small bowel reconstruction to limit absorption
43770 Laparoscopic surgical gastric restrictive procedure. Placement of adjustable gastric band
43842 Gastric restrictive procedure, without gastric bypass; vertical-banded gastroplasty (VBG)
43843 Gastric restrictive procedure, other than vertical-banded gastroplasty
43845 Biliopancreatic diversion with duodenal switch
43846 Gastric restrictive surgery, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en Y gastroenterostomy
43847 Gastric restrictive surgery, with gastric bypass and Roux-en Y gastroenterostomy (roux limb 150 cm or less) with small bowel reconstruction to limit absorption
43848 Revision of gastric restrictive procedure for morbid obesity (separate procedure)
If not, then this surgery need not be reported.
For the above procedures, is this the first surgery this patient has had related to their morbid obesity? If yes, then was this surgery performed on or after July 1, 2006? If yes, this surgery must be reported.
If this is not the first surgery this patient has had related to their morbid obesity, was this surgery performed because of a complication or side effect of the initial surgery? If yes, was the initial surgery one of the above procedures that was performed on or after July 1, 2006? If yes, this surgery must be reported in a follow-up report to the initial surgery.
2. Which follow-up visits do I report?
Was this patient’s initial (first or only) surgery for morbid obesity performed on or after July 1, 2006? If yes, then follow-up visits at 30, 60, 90 days, and 1 year after that initial surgery must be reported.
Note: do not report follow-up visits on patients whose initial surgery was performed before July 1, 2006. Do not report additional visits which take place between the required follow-up intervals. Do not report follow-up after 1 year unless death or a complication/side effect of surgery resulting in permanent disability has occurred. Use the appropriate annual report for those events.
It is understood that the patients’ and physicians’ schedules may not permit follow-up visits to be scheduled at precisely these times. It is also understood that patients may at times cancel or not appear for scheduled follow-up visits. Report the follow-up visit information that is available. For example, if the patient schedules a visit at 40 rather than 30 days, report information from that visit as the 30 day follow-up and note the date of the follow-up in the comment box in Section 3.
3. We usually see our patients at different follow-up intervals from the ones on the form, how do we report our follow-up visits?
Many patients will be seen for follow-up before 30 days, between the prescribed intervals, and at various intervals after the first year. You are required to report information from follow-up visits at 30, 60, and 90 days post surgery, and at 1 year after surgery.
4. When do I report?
Surgeries performed between July1, 2006 and December 31, 2006 and 30, 60, or 90 day follow-up visits to those surgeries which took place before December 31, 2006 should have been reported before the end of the one-time extension period. Surgeries performed between January 1, 2007 and June 30, 2007 and 30, 60, 90 day and 1 year follow-up visits to surgeries performed on or after July 1, 2006 should have been reported before December 31, 2007. Subsequent surgeries and 30, 60, 90 day, and 1 year follow-ups must be reported before June 30 for cases in the last 6 months of the preceding year and before December 31 for the first 6 months of the current year. Please note that June 30 and December 31 are deadlines. Surgery and follow-up reports may be submitted anytime after discharge or after the office visit until the deadline for each case.
5. What information must I report?
You must report, to the extent that the information exists, all information requested on the form prescribed by the State Department of Health.
Section 1. This information includes the patient’s
County of residence
Current phone number
Date of birth and age at time of surgery or follow-up
For the initial report:
Baseline BMI and waist circumference
Whether the patient had previous abdominal surgery or not
Comorbidities at the time of surgery using ICD-9-CM codes (If there is insufficient space, list additional information in the comments box in Section 3.)
Surgical diagnosis (ICD-9-CM code and description)
Surgical procedure (CPT code and description) (If more than one procedure for morbid obesity was performed during the initial surgery, please note the code and description in the procedure box.)
For follow-up reports:
The follow-up interval (Please check one.)
CPT code for the initial surgery
CPT codes for any separate surgical procedures performed at the time of the initial surgery
Follow-up (at interval) BMI and waist circumference
Comorbidities (ICD-9-CM codes) present at time of interval follow-up (Use comments section, if necessary, for additional comorbidities.
Indication (yes or no) of the occurrence of death, complications of surgery, or side effects from the initial surgery
If death, cause (ICD-10 code) and date of death
If complication(s), ICD-9-CM code(s) and date(s) of onset
Whether patient was hospitalized for the complication (yes or no), name of facility, length of stay, and status at time of discharge (Check one and, if status is “Other Institution”, please, indicate which type.)
Whether surgery was performed for the complication(s) (yes or no) and if yes, date of surgery and CPT code(s) for the procedures performed
Whether other invasive treatment was required for the complication(s) and a description of that treatment
If side effect(s), ICD-9-CM code(s) and date(s) of onset
Whether patient was hospitalized for the side effect (yes or no), name of facility, length of stay, and status at time of discharge (Check one and, if status is “Other Institution”, please, indicate which type.)
Whether surgery was performed for the side effect (s) (yes or no) and if yes, date of surgery and CPT code(s) for the procedures performed
Whether other invasive treatment was required for the side effect(s) and a description of that treatment
For all reports:
Surgeon’s Indiana Medical License Number
Surgeon’s full name, address, telephone number, FAX number
Any additional information for sections 1 and 2
Name of the person completing the form and a phone number where they can be reached during regular business hours
Date the form was completed
6. Do we have to use the codes?
Yes. The codes are necessary for the computing of aggregate statistics. These are the same codes that are used for billing purposes and almost all medical offices have copies of the code books.
7. We don’t know the date of onset of a complication or side effect, can we leave that space blank?
First, make every effort to obtain that information. Frequently, there will be information in the patient’s record indicating how long a problem has been present. You can use this information to give an estimated date of onset. If the patient has an upcoming appointment or has had lab tests done, you can ask the onset date when the patient is called for a reminder or to give results. Only if there is no information in the patient’s record to give an approximate onset date, and the information cannot be obtained from the patient, should the space for the onset date be left blank.