Medicare Benefits Schedule - Note TN.8.29

Items 31569 to 31581 and item 20791 provide for surgical treatment of clinically severe obesity and the accompanying anaesthesia service (or similar).  The term clinically severe obesity generally refers to a patient with a Body Mass Index (BMI) of 40kg/m² or more, or a patient with a BMI of 35kg/m² or more with other major medical co-morbidities (such as diabetes, cardiovascular disease, cancer).  The BMI values in different population groups may vary due, in part, to different body proportions which affect the percentage of body fat and body fat distribution.  Consequently, different ethnic groups may experience major health risks at a BMI that is below the 35-40 kg/m² provided for in the definition.  The decision to undertake obesity surgery remains a matter for the clinical judgment of the surgeon. 

If crural repair taking 45 minutes or less is performed in association with the bariatric procedure, additional hernia repair items cannot be claimed for the same service.

Practitioners providing items 31569, 31572, 31575 and 31581 should be registered with and provide relevant data to the Bariatric Surgery Registry.

Related Items: 20791 31569 31572 31575 31578 31581

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Initiation of the management of anaesthesia for bariatric surgery in a patient with clinically severe obesity

(10 basic units)

Fee: $218.00 Benefit: 75% = $163.50 85% = $185.30

(See para TN.8.29 of explanatory notes to this Category)

Multiple Operation Rule

Adjustable gastric band, placement of, with or without crural repair taking 45 minutes or less, for a patient with clinically severe obesity

(Anaes.) (Assist.)

Fee: $935.15 Benefit: 75% = $701.40

(See para TN.8.29 of explanatory notes to this Category)

Multiple Operation Rule

Gastric bypass by Roux-en-Y including associated anastomoses, with or without crural repair taking 45 minutes or less, for a patient with clinically severe obesity not being associated with a service to which item 30515 applies

(Anaes.) (Assist.)

Fee: $1,150.70 Benefit: 75% = $863.05

(See para TN.8.29 of explanatory notes to this Category)

Multiple Operation Rule

Sleeve gastrectomy, with or without crural repair taking 45 minutes or less, for a patient with clinically severe obesity

(Anaes.) (Assist.)

Fee: $935.15 Benefit: 75% = $701.40

(See para TN.8.29 of explanatory notes to this Category)

Multiple Operation Rule

Gastroplasty (excluding by gastric plication), with or without crural repair taking 45 minutes or less, for a patient with clinically severe obesity

(Anaes.) (Assist.)

Fee: $935.15 Benefit: 75% = $701.40

(See para TN.8.29 of explanatory notes to this Category)

Multiple Operation Rule

Gastric bypass by biliopancreatic diversion with or without duodenal switch including gastric resection and anastomoses, with or without crural repair taking 45 minutes or less, for a patient with clinically severe obesity

(Anaes.) (Assist.)

Fee: $1,150.70 Benefit: 75% = $863.05

(See para TN.8.29 of explanatory notes to this Category)