Current Procedural Terminology, or CPT codes, form the standardized language used by healthcare providers to describe medical, surgical, and diagnostic services to public and private payers. These five-digit codes are fundamental to the administrative process, ensuring that the services rendered are accurately documented and billed for reimbursement. CPT code 43775 specifically identifies a laparoscopic sleeve gastrectomy, a restrictive bariatric operation performed for the treatment of morbid obesity. Understanding this code requires looking beyond the digits themselves to encompass the complex surgical procedure it represents, the specific rules governing its billing, and the strict patient criteria required for insurance coverage.
Defining the Sleeve Gastrectomy Procedure
The service represented by CPT code 43775 is a permanent surgical alteration of the stomach performed using a minimally invasive, laparoscopic approach. During this procedure, the surgeon utilizes several small incisions in the abdomen to insert a camera and long surgical instruments to access the stomach. The abdomen is first inflated with carbon dioxide gas to create a working space, a technique known as insufflation.
The core of the operation involves dividing the stomach vertically to remove approximately 80 to 90 percent of the organ. The surgeon uses a stapling device to separate and excise the greater curvature of the stomach, converting the large, pouch-like stomach into a narrow, tube-like structure. This new structure is often described as resembling a sleeve, which is the source of the procedure’s name.
This technique is classified as a purely restrictive bariatric operation because it significantly limits the volume of food a patient can consume at one time. It does not reroute the small intestine, meaning food absorption is not intentionally reduced, which distinguishes it from malabsorptive procedures like a gastric bypass. The restrictive effect is immediate, contributing to early satiety, which is the feeling of fullness after eating small amounts.
Beyond physical restriction, the procedure also induces metabolic changes that contribute to weight loss and the resolution of obesity-related diseases. The portion of the stomach that is removed is the fundus, which is the primary site of production for the hormone ghrelin. Ghrelin is often referred to as the “hunger hormone” because it stimulates appetite, and its reduced production after surgery is believed to contribute to a sustained decrease in hunger sensation for the patient.
Applying the Code in Billing
The use of CPT code 43775 in billing is governed by the principles of the Global Surgical Package, a standardized reimbursement policy for surgical procedures. For major procedures like the laparoscopic sleeve gastrectomy, this package includes a 90-day global period. This period covers the procedure itself, a pre-operative visit the day before surgery, and all routine post-operative visits for 90 days following the operation.
The financial reimbursement for CPT 43775 is bundled into this single payment. Routine follow-up care, such as wound checks, staple removal, and standard E/M visits related to the patient’s recovery from the surgery, cannot be billed separately. The 90-day period begins on the day of the surgery and extends for the subsequent three months. Any services performed by the operating surgeon or another physician in the same specialty group during this window are considered part of the global fee, unless a specific exception applies.
Exceptions to the Global Surgical Package require the use of a CPT modifier, a two-digit code appended to the procedure code to provide additional information to the payer. If the surgeon has to perform an unusually complex procedure requiring significantly more time and effort, the -22 modifier (Increased Procedural Services) may be used to request additional reimbursement. Conversely, the -52 modifier (Reduced Services) would be applied if the full service described by 43775 was partially reduced or eliminated.
If a patient requires an evaluation and management (E/M) service during the 90-day post-operative period for a medical condition unrelated to the surgery, the surgeon can bill for that service separately using the -24 modifier. This signals to the insurance payer that the visit was for a distinct and separate problem, such as a severe migraine or a new respiratory infection. The correct application of these modifiers is necessary for compliant submission of the surgical claim.
Criteria for Insurance Coverage
Securing coverage for the laparoscopic sleeve gastrectomy, identified by CPT 43775, typically involves a rigorous Prior Authorization (PA) process mandated by most major insurance payers. The patient must demonstrate that the procedure is medically necessary according to predefined clinical guidelines. A primary requirement across most policies is a specific Body Mass Index (BMI) threshold, which must be met or exceeded for the patient to be considered a candidate.
In most cases, a patient must have a BMI of 40 or greater, regardless of any other coexisting health issues. Alternatively, a patient with a BMI of 35 to 39.9 may qualify if they also have at least one or two significant obesity-related comorbidities. Common qualifying conditions include Type 2 diabetes, severe obstructive sleep apnea, hypertension, or high cholesterol. The presence of these specific diseases demonstrates the medical necessity of intervention to improve the patient’s overall health.
Qualifying Comorbidities
Most policies recognize the following conditions:
- Type 2 diabetes
- Severe obstructive sleep apnea
- Hypertension
- High cholesterol
In addition to meeting the physical criteria, patients are required to provide extensive documentation of their efforts to lose weight through non-surgical means. This typically involves a medically supervised weight management program, which must be documented over a period that can range from three to six months. This supervised program serves to verify that the patient has exhausted conservative treatment options and is capable of adhering to the structured lifestyle changes necessary for long-term success.
Furthermore, most insurance policies require a comprehensive psychological evaluation before approval is granted. This assessment ensures the patient is mentally prepared for the significant lifestyle adjustments and emotional challenges that follow bariatric surgery. The successful navigation of all these administrative and clinical hurdles is required before the CPT code 43775 can be submitted for a covered and reimbursed procedure.