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Bariatric & Metabolic Surgery Billing Services
Qualigenix bills sleeve gastrectomy, gastric bypass, banding, duodenal switch and revision surgery for bariatric programs, from the prior authorization through the 90-day global period.
What Does Bariatric Surgery Billing Require?
Bariatric surgery billing requires proof that the patient meets the payer's medical necessity criteria, an approved authorization before the date of surgery, and procedure codes that separate primary operations from revisions. Qualigenix builds the authorization packet, codes the operation with CPC- and CCS-certified coders, and manages the 90-day global period that follows. Call 786-259-0231 to talk through your program.
01
Primary vs Revision Coding
A sleeve converted to a bypass, a band removed during another procedure, or a revised gastric bypass each code differently from a first operation. Payers also apply separate criteria to revisions, so a revision billed under a primary code can be denied even after the surgery was approved.
02
Payer Approval for Surgery
Commercial and Medicaid policies commonly require prior authorization for bariatric surgery. Maryland Medicaid, for example, lists 43644, 43645, 43770 to 43775, 43842, 43843 and 43845 to 43848 as codes that need preauthorization. An approval also has an end date, and a surgery that moves past it is billed without coverage.
03
Pre-Op Program Requirements
Payer policies list steps a patient must finish before surgery, and some commercial policies require a documented history of severe obesity for at least two years. When a required step isn't in the record, the authorization request comes back.
04
90-Day Global & Post-Op Visits
Bariatric operations carry a 90-day global period, so routine follow-up visits are included in the surgical payment. A visit for an unrelated problem needs modifier 24, and a return to the operating room for a complication such as bleeding or obstruction needs modifier 78.
05
Plan Exclusions & Benefit Checks
Bariatric coverage is set plan by plan, and a patient can have active insurance with no bariatric benefit. Verification has to confirm that the procedure is covered, which facilities qualify and what the plan requires before surgery.
06
BMI & Comorbidity Documentation
Medicare covers bariatric surgery for patients with a BMI of 35 or higher, at least one obesity-related comorbidity and a prior unsuccessful attempt at medical treatment. The obesity class codes added in October 2024 (E66.811 to E66.813) apply only when the provider documents the class, and a BMI value in the chart doesn't replace a provider's obesity diagnosis.
07
Medical Necessity Denials
When the diagnosis codes on the claim don't show the BMI and comorbidity the policy requires, payers deny the surgery as not medically necessary. Those denials need an appeal built from the chart, not a resubmission of the same claim.
08
NCD 100.1 & Payer Criteria
Medicare's National Coverage Determination 100.1 sets the federal criteria, and each commercial plan writes its own. A program that bills both has to track two sets of requirements for the same procedure.
How Qualigenix Closes Each Bariatric Gap
Qualigenix assigns each step of the bariatric billing cycle to a coder or authorization specialist who completes it before the claim goes out.
Procedure & Revision Coding
Coders read the operative note for prior bariatric surgery and code revisions as revisions, using the code each payer's policy names where policies differ.
Surgical Prior Auth Packets
We build the authorization request from the chart: BMI history, comorbidities, prior weight-loss attempts and completed pre-op steps, matched to the payer's policy. The approval's end date is tracked so surgery happens inside it.
Pre-Op Program Tracking
Each patient's nutrition, psychology and clearance visits are tracked against the payer's checklist, so the request goes out complete.
Global Period Management
Post-op visits are logged against the 90-day global period, and only unrelated visits or procedures are billed, with modifier 24, 78 or 79.
Bariatric Benefit Verification
Before a patient enters the program, we confirm the plan covers bariatric surgery and record any facility or pre-op requirements.
BMI & Comorbidity Checks
Coders confirm that the obesity code, BMI code and comorbidity codes on the claim match the provider's documentation.
Appeals Backed by Clinical Proof
Medical necessity denials are appealed with the chart evidence the policy asks for. Qualigenix overturns 79% of the denials it works, with an average appeal turnaround under 9 days.
Coverage Criteria Monitoring
We track NCD 100.1 and each contracted payer's bariatric policy, so every authorization packet matches the version in force.
CASE STUDY 01
How a 3-provider podiatry group cleared $214K in aged A/R
THE SITUATION
A 3-provider podiatry group with roughly 60% Medicare payer mix carried $412,000 in A/R, 38% of it past 120 days. Routine foot care claims (11720, 11721, 11055–11057) had stalled on inconsistent Q7/Q8/Q9 modifiers and class-finding documentation, so payers held or partially paid and nobody worked the remainder. Medicare crossover to secondaries was not being posted, and small patient balances were written off.
WHAT QUALIGENIX DID
We ran a full A/R aging segmentation, worked claims by payer and denial reason rather than by date, rebilled the stalled routine-care claims with corrected modifiers, and reactivated secondary and crossover billing.
Key Outcomes & Turnaround
38% to 14%A/R past 120 days
$214,000recovered from aged A/R
90 daysto turn it around
~60%Medicare payer mix
Audited Practice Results
How a solo podiatrist lifted first-pass acceptance to 96%
THE SITUATION
A solo podiatrist coding 320 encounters a month was stuck at 82% first-pass acceptance. Routine foot care went out without the systemic-condition diagnosis pairing and class findings Medicare requires, so it read as non-covered. Wound debridement was coded to the wrong depth (11042 for skin and subcutaneous where the note supported 11043 for muscle and fascia). Same-day E/M with a procedure went out without modifier 25 and got bundled.
WHAT QUALIGENIX DID
We rebuilt the coding workflow: diagnosis-to-CPT pairing rules for at-risk foot care, correct Q-modifier logic, depth-based debridement coding tied to the operative note, and disciplined use of modifiers 25 and 59/XS.
Key Outcomes & Turnaround
82% to 96%first-pass acceptance
+11%per-encounter reimbursement
60 daysto turn it around
320/moencounters coded
Audited Practice Results
How a 2-location podiatry practice cut its denial rate by two-thirds
THE SITUATION
A 2-location podiatry practice sat at a 19% denial rate, mostly Medicare routine-foot-care and nail-debridement rejections. The denials clustered in three buckets: medical-necessity rejections on routine foot care (missing qualifying diagnosis and class findings), frequency-edit denials on nail debridement billed inside the 60-day window, and missing Q modifiers that flagged services as non-covered.
WHAT QUALIGENIX DID
We built a front-end denial-prevention layer, checking eligibility and coverage against payer LCDs before claims went out, plus a structured appeal workflow with documentation templates mapped to each denial reason.
Key Outcomes & Turnaround
19% to 6%denial rate
$68,000recovered on appealed claims
4 monthsto turn it around
2 locationspractice size
Audited Practice Results
Bariatric Coding by Procedure
Bariatric procedure codes split by approach, by anatomy and by whether the operation is a first procedure or a revision.
Sleeve Gastrectomy
43775 is laparoscopic sleeve gastrectomy, with a 90-day global period. Payer prior authorization policies list it by code, and the claim needs an obesity diagnosis and a BMI code that match the approval.
COMPLIANCE
Bariatric Programs We Support
Bariatric surgery centers Metabolic surgery programs Accredited bariatric centers Multidisciplinary weight management clinics Hospital-based bariatric programs
0%
Audit Pass Rate
<0%
Variance Threshold
Why Qualigenix
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IMPROPER PAYMENT RATE
0%
FROM DOC GAPS
0%
FROM CODING ERRORS
$0M+
PAID IN ERROR
QUESTIONS BUYERS ASK
Qualigenix charges a percentage of collections, so the fee moves with what your program is paid. The percentage depends on volume and scope and is quoted after we review your claim mix. Call 786-259-0231 to start that conversation.
It depends on the payer. Some revision policies list the gastric bypass code 43644, and others call for an unlisted code, so we check the payer's policy and the operative note before choosing.
Payers want the obesity diagnosis (E66.01, or a class code from E66.811 to E66.813), the matching BMI code such as Z68.35 to Z68.45 for adults with a BMI of 35 or more, and codes for the comorbidities that support surgery.
Yes. We work open bariatric claims by age, payer and denial reason, starting with the oldest balances. Qualigenix's A/R work has cut days in A/R from 54 to 36.
A bariatric packet carries the patient's BMI history, obesity-related comorbidities, documented prior weight-loss attempts and the pre-op steps the payer requires. Qualigenix matches each packet to the payer's current policy before sending it.
Yes, under NCD 100.1, for patients with a BMI of 35 or higher, at least one obesity-related comorbidity and a prior unsuccessful attempt at medical treatment. Procedures named in the NCD include gastric bypass, adjustable gastric banding and duodenal switch.
Yes. Qualigenix works in the EHR and practice management system you already use and has worked across 133 EMR and EHR platforms.
Qualigenix onboards new practices in 6 days on average. Call 786-259-0231 to plan your start date.