Weight loss surgery or bariatric surgery is very effective for severe and medically complicated obesity with associated risks, even death. This treatment is used when less invasive weight loss methods fail. However, there are several risks associated with the surgery itself such as blood clot, excessive bleeding, lung or breathing problems and so on. In addition to this, longer term risks and complications are there for the procedure according to the type of surgery. Clear and complete clinical documentation of patients’ health condition is essential to address these issues effectively and make the treatment effective. Accurate documentation is important for getting coverage also. Here are the major scenarios where documentation plays a crucial role in bariatric surgery.
According to the National Institutes of Health, bariatric surgery is recommended as a treatment option for severe obesity if a person weighs 100 pounds or more above the ideal body weight, or have a Body Mass Index (see our BMI calculator) of 40 or greater, or a BMI of 35 or greater with one or more obesity-related health conditions that are known to improve with weight loss attempts such as diabetes, sleep apnea, high blood pressure, osteoarthritis, GERD, or metabolic syndrome among others. Either physicians or non-physicians (dieticians or nurses) should document the patient’s clinical condition very clearly during their admission assessments so that BMI can be coded correctly. The medical history reports of patients should be complete and incorporate the results of all the treatments they have undergone to lose weight. It is very important to document the details of psychiatric evaluation (if any) in medical history. Patients undergoing this surgery should be between 18-70 years of age and must not have advanced or irreversible medical conditions including end stage liver disease, crohn’s disease etc. Patient demographics should be documented well for that along with the results of pre-operative tests.
Most insurers review requests for prior authorization on the basis of medical necessity. The medical necessity is determined on a combination of clinical data as well as the presence of indicators that affect relative risks and benefits of the procedure. So, the prior authorization requests should be accompanied by documentation that supports medical necessity. Generally, the documentation should include the following:
- Details of diagnosis and description of the pre- and post- surgical treatment plans
- Summary of the medical history and the last physical exam that includes height, weight, patient and family history, personal and social history and medications (past and current)
- Details about the diagnostic and/or laboratory tests related to the diagnosis and co-morbid conditions if present
- Details about substance abuse (if any) and how severe it is
- Details about previous surgeries, hospitalizations, initial and follow-up nutritional evaluation, psychological evaluation and description of multidisciplinary aftercare plan
- Pre-operative weight history including the details of weight loss attempts
However, the documentation requirements may vary according to the insurer. Follow up with the insurer to ensure if the documentation includes all the details.
Repeat bariatric surgery is performed when primary surgery failed due to some reasons, or for the replacement of the gastric band. Most of the insurers provide coverage for this if the previous surgery was medically necessary. You also need to prove the repeat surgery is medically necessary for the patient. For example, certain insurers insist that replacement of an adjustable gastric band can be considered as a medically necessary procedure, if there are some complications (for example, port leakage) that cannot be corrected with either band manipulation or adjustments. Here too, there should be accurate and complete documentation that explains the reasons for repeat surgery and ensure that they support the medical necessity requirements of insurers.