For about a year now, Medicare hasn’t reimbursed a hospital in Kansas City, Missouri, and presumably other hospitals, for a type of laparoscopic bariatric surgery—Biliopancreatic Diversion with Duodenal Switch (BPD/DS)—when it’s performed on inpatients. This went unnoticed for a time because Medicare wasn’t denying the claims for the most part; they came back as contractual write-offs. When the hospital took a closer look at zero-pay, high-dollar services generally, it discovered that its Medicare administrative contractor (MAC) wasn’t paying for inpatient laparoscopic BPD/DS procedures across the board in the way they were billed based on a provision in the Medicare Claims Processing Manual.

But that doesn’t square with the national coverage determination (NCD) on gastric bypass surgery for obesity (NCD 100.1), said Richelle Marting, director of managed care at the hospital.^[1] The disconnect isn’t sitting well with her because NCDs are binding and manuals are just guidance, yet it’s the guidance that is interfering with access to coverage and payment in the circumstances the NCD intends to cover.

“I haven’t run into a scenario quite like this before,” Marting said. She has brought it to the attention of CMS, which she said has “acknowledged they’re working on it.” But these things take time.