Effective Date:

October 1, 2022

Purpose:

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

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

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.

Gastropexy: A surgical operation in which the stomach is sutured to the abdominal wall or the diaphragm.

Policy:

Horizon NJ Health shall not reimburse separately for the hiatal hernia, gastropexy or related incidental procedures when performed with bariatric surgery on the same date of service using inappropriate CPT codes, including, but not limited to, the following codes.

Procedure:

Horizon NJ Health will not consider for reimbursement the hiatal hernia repair, gastropexy and/or related incidental procedures (indicated in this policy) when billed with a bariatric surgery procedure on the same date of service regardless if a modifier -59 is appended.

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.