Current Procedural Terminology (CPT) codes are a standardized, five-digit language for describing medical, surgical, and diagnostic services. CPT code 43775 is specifically designated for a complex surgical procedure known as a Laparoscopic Sleeve Gastrectomy. The code’s full descriptor is “Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy).” This designation ensures that when a provider submits a claim, the payer understands the precise, minimally invasive operation that was performed.
Decoding CPT 43775: The Laparoscopic Sleeve Gastrectomy
The procedure represented by CPT 43775 is a bariatric operation that physically reduces the stomach’s size to promote weight loss. It is performed using a laparoscopic approach, involving specialized instruments inserted through several small incisions. This minimally invasive technique avoids the large abdominal incision associated with traditional open surgery, leading to shorter recovery times and reduced scarring.
The core of the surgery, known as longitudinal gastrectomy, involves removing approximately 75 to 80% of the stomach. The surgeon uses a specialized stapling device to divide the stomach vertically, creating a narrow, tube-like structure, or “sleeve,” that resembles a banana. The excised portion, which includes the greater curvature of the stomach, is then removed from the body.
This anatomical change significantly reduces the stomach’s volume, physically limiting the amount of food a person can consume. The surgery also impacts physiological signaling by removing the section of the stomach that produces the majority of the hunger-inducing hormone ghrelin. This hormonal shift often leads to a decrease in appetite and changes in metabolism, aiding in the treatment of conditions like Type 2 diabetes. The procedure preserves the pyloric valve, which controls the emptying of the stomach into the small intestine, helping prevent dumping syndrome often seen in other bariatric surgeries.
How the Code is Used in Medical Billing and Insurance
CPT code 43775 is the administrative tool healthcare providers use to inform insurance companies that a laparoscopic sleeve gastrectomy was performed. The code is submitted as part of a formal claim alongside an International Classification of Diseases (ICD-10) code, which states the patient’s diagnosis, such as morbid obesity with associated co-morbidities. The combination of the procedural code and the diagnostic code is essential for establishing the medical necessity of the surgery.
Bariatric surgery coverage requires strict adherence to specific medical necessity criteria, such as a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with a serious weight-related health condition like diabetes or severe sleep apnea. Most payers, including Medicare, require extensive documentation and pre-authorization before the procedure can be performed and billed. This pre-approval process confirms that the patient meets all clinical prerequisites, including a documented history of unsuccessful attempts at non-surgical weight loss.
The base code 43775 may sometimes be accompanied by a two-digit modifier to provide additional context about the service provided. For example, Modifier 22, “Increased Procedural Services,” may be appended if the surgery was substantially more complex or time-consuming than usual due to a patient’s unique anatomy or scar tissue. Modifier 59, “Distinct Procedural Service,” is used if the surgeon performed a separate, non-related procedure during the same operative session, such as a hiatal hernia repair. These modifiers help ensure accurate and appropriate reimbursement for the specific circumstances of the operation.
Services Included and Excluded from CPT 43775
The reimbursement associated with CPT 43775 covers the primary surgical event and the work of the surgeon. This includes the surgeon’s fee, the standard pre-operative and post-operative care immediately surrounding the procedure, and the professional component of the surgical team’s effort. The code bundles all routine intraoperative care directly related to performing the gastrectomy.
However, many significant costs associated with the overall treatment plan are not covered by this single surgical code and are billed separately. The facility fee, which covers the hospital stay, operating room time, and surgical supplies, is billed by the hospital using different codes. Anesthesia services are often billed by an independent anesthesiologist or a separate group using their own specialized codes.
Furthermore, the extensive pre-operative work-up is excluded from CPT 43775, requiring its own set of codes. This preparation often includes nutritional counseling, psychological evaluations, and various diagnostic tests like blood work, all billed as distinct services. Long-term post-operative follow-up visits, which occur after the global surgical period, are also billed separately using Evaluation and Management (E/M) codes, ensuring that the surgeon is compensated for the patient’s ongoing medical management.