Find comprehensive information on gastric bypass surgery diagnosis, including ICD-10 codes, CPT codes, clinical documentation improvement tips, postoperative complications, and healthcare coding guidelines. Learn about Roux-en-Y gastric bypass, laparoscopic gastric bypass, and open gastric bypass procedures. Explore resources for medical billing, coding compliance, and accurate clinical documentation for bariatric surgery. This guide provides essential information for healthcare professionals, coders, and billers involved in the management of gastric bypass patients.
Also known as
Bypass of stomach with other procedures
Surgical bypass of the stomach combined with other procedures.
Other bypass of stomach
Other surgical procedures involving bypass of the stomach.
Revision of gastric bypass
Surgical revision of previous gastric bypass procedures.
Personal history of other surgery
Indicates a past history of gastric bypass surgery.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the gastric bypass Roux-en-Y?
Yes
Open or laparoscopic?
No
Is it a laparoscopic other bypass?
When to use each related code
Description |
---|
Gastric Bypass |
Gastric Sleeve |
Adjustable Gastric Band |
Coding lacks specificity (e.g., Roux-en-Y, open/laparoscopic) impacting DRG assignment and reimbursement. CDI review crucial.
Incomplete coding of obesity-related comorbidities (e.g., diabetes, hypertension) affects risk adjustment and payment.
Failure to capture and code intraoperative complications (e.g., bleeding, anastomotic leak) leads to underreporting severity.
Patient presents for postoperative follow-up after Roux-en-Y gastric bypass surgery (RYGB). The procedure was performed on [Date of Surgery] for the treatment of morbid obesity and obesity-related comorbidities including [List comorbidities, e.g., type 2 diabetes mellitus, hypertension, obstructive sleep apnea]. Current weight is [Weight] kg with a BMI of [BMI]. Preoperative weight was [Weight] kg with a BMI of [BMI]. The patient reports [Symptom, e.g., good tolerance of a soft diet, occasional nausea, no vomiting]. Physical examination reveals a well-healing surgical incision site with no signs of infection or complications such as wound dehiscence or abdominal hernia. Abdominal examination is unremarkable. Current medications include [Medications, e.g., multivitamins, iron supplements, proton pump inhibitor]. Patient education was provided regarding dietary guidelines for bariatric surgery patients, including the importance of protein intake, hydration, and avoiding dumping syndrome. The patient demonstrates understanding of postoperative care instructions and potential complications including marginal ulcer, anastomotic leak, and vitamin deficiencies. Plan includes continued monitoring of weight loss, nutritional status, and resolution of comorbid conditions. Follow-up appointment scheduled for [Date] to assess progress and address any concerns. Diagnosis: Status post Roux-en-Y Gastric Bypass. ICD-10 code: Z98.84 (Personal history of bariatric surgery). CPT codes for follow-up visits will vary depending on complexity and time spent with the patient.