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Z98.84
ICD-10-CM
Gastric Bypass Surgery

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

Roux-en-Y Gastric Bypass
RYGB

Diagnosis Snapshot

Key Facts
  • Definition : Surgical reduction of stomach size to restrict food intake and induce weight loss.
  • Clinical Signs : Significant weight loss, nausea, vomiting, dumping syndrome, abdominal pain, vitamin deficiencies.
  • Common Settings : Hospital operating room, bariatric surgery clinic, outpatient follow-up appointments.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z98.84 Coding
0DB60ZZ-0DB64ZZ

Bypass of stomach with other procedures

Surgical bypass of the stomach combined with other procedures.

0DB67ZZ-0DB69ZZ

Other bypass of stomach

Other surgical procedures involving bypass of the stomach.

0DB90ZZ-0DB94ZZ

Revision of gastric bypass

Surgical revision of previous gastric bypass procedures.

Z98890

Personal history of other surgery

Indicates a past history of gastric bypass surgery.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Gastric Bypass
Gastric Sleeve
Adjustable Gastric Band

Documentation Best Practices

Documentation Checklist
  • Gastric bypass surgery documentation: Pre-op diagnosis, BMI, comorbidities
  • Operative report: Roux-en-Y, sleeve, or other bypass technique specified
  • Complications: Anastomosis leak, bleeding, stricture documented if present
  • Post-op plan: Diet, follow-up, pain management clearly outlined
  • ICD-10-PCS code assignment: Verify code for specific bypass procedure

Coding and Audit Risks

Common Risks
  • Unspecified Bypass Type

    Coding lacks specificity (e.g., Roux-en-Y, open/laparoscopic) impacting DRG assignment and reimbursement. CDI review crucial.

  • Comorbidity Capture

    Incomplete coding of obesity-related comorbidities (e.g., diabetes, hypertension) affects risk adjustment and payment.

  • Intraoperative Complication Coding

    Failure to capture and code intraoperative complications (e.g., bleeding, anastomotic leak) leads to underreporting severity.

Mitigation Tips

Best Practices
  • Code Z98.84 for gastric bypass history. Improves data accuracy.
  • Specific bypass type in op note (Roux-en-Y etc.) for accurate coding.
  • Thorough documentation of comorbidities impacts risk adjustment & coding.
  • Pre-op BMI, operative details, and post-op complications must be documented.
  • Regular CDI reviews ensure accurate coding and optimized reimbursement.

Clinical Decision Support

Checklist
  • Verify BMI >=40 or BMI >=35 with comorbidities (ICD-10-CM E66.01)
  • Confirm documented failure of non-surgical weight loss (E66.1)
  • Psychological evaluation and clearance documented (Z71.8)
  • Pre-operative assessment including nutritional status (Z71.3)
  • Informed consent obtained and documented (Z01.810)

Reimbursement and Quality Metrics

Impact Summary
  • Gastric Bypass Surgery Reimbursement: Coding accuracy impacts payer contract adherence, influencing case mix index and hospital revenue cycle.
  • Quality Metrics Impact: Accurate ICD-10-PCS and CPT coding affects surgical site infection (SSI) reporting and hospital quality scores.
  • Readmission Reduction: Proper coding for complications and comorbidities influences readmission rates and value-based purchasing.
  • Data Integrity: Correct coding ensures accurate data for clinical registries and research, improving patient outcomes analysis.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code primary bypass procedure
  • Document pouch size/type
  • Specify open/laparoscopic
  • Code complications separately
  • Note revision/conversion status

Documentation Templates

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.