Bariatric Surgery Billed With Hiatal Hernia Repair

Reimbursement Policy:
Bariatric Surgery Billed With Hiatal Hernia Repair

Effective Date:
March 1, 2014

Last Revised Date:
February 26, 2015

Purpose:
This policy provides reimbursement guidelines for the denial of hiatal hernia procedures when billed with bariatric surgery.

Scope:
All products are included except:

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Host Medicare Advantage PPO Non-Par
  • ITS Host Medicare Advantage Non-PPO
  • ITS Home Par
  • Flexlink
  • MPL Non Par

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
Surgery for Obesity (Bariatric surgery): Treatment for morbid obesity in patients who fail to lose weight with conservative measures.

Hiatus Hernia (Hiatal Hernia): The protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.

Policy:
Horizon BCBSNJ shall not reimburse separately for the hiatal hernia procedure when performed with bariatric surgery on the same date of service using inappropriate CPT codes, including, but not limited to, the following codes:

  • Internal Hernia Repair Codes: 43280, 43281, 43282, 43283
  • Bariatric Surgery Codes: 43770, 43771, 43772, 43773, 43774, 43775

Procedure:
Deny the hiatal hernia repair codes as incidental or mutually exclusive when billed with the bariatric surgery codes.

Modifier 59 may not be applied to the hiatal hernia codes. Hiatal hernia codes submitted with Modifier 59 will deny.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit.
  • Provider Participation Agreement.
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
  • Mandated or legislative required criteria will always supersede.

CPT® is a registered trademark of the American Medical Association.

Policy 076_v1.0_05202015