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Is VAD battery replacement billable in office setting

Angel Posted Fri 05th of April, 2019 09:32:02 AM
Hello, my provider saw a pt, in office after his power module started alarming and his pump stopped. Pt. had not had his equipment serviced since 2016. Both controllers and lead acid battery were expired. The patient presents to our clinic today after his power module started alarming and his pump stopped. Patient had not had his equipment serviced since 2016. After interrogation of the VAD was completed, it was found that both controllers and the lead acid battery were expired. Patient pocket controllers (PC-52111 and PC- 44512-K) replaced with PCX-15947 exp 4/17/2021 (on patient with back-up battery 106128 SN SS053127 exp 1/22/2020) and PCX-15945 exp 4/17/2021 (with back-up battery 106128 SN SS053129 exp 1/22/2020). Lead acid battery also replaced in the patient's power module. Patient equipment wiped down with Lysol wipes and quantified as follows: 8 Li-Ion Batteries due for replacement in October (instructed on how to configure over the next 8 nights) 2 Clips (needs 2 now) 1 controller and 1 back-up controller (just replaced) 1 battery charger due for replacement in October 1 power module due for replacement in October NEEDS: 2 Clips NOW 8 Li-Ion Batteries, 1 Battery Charger, 1 Power Module to be ordered in October. -----This was billed as Q0496 and Q0481 both have denied as not payable in the office setting.. I cannot find any documentation stating it is only payable as inpatient.
SuperCoder Answered Mon 08th of April, 2019 05:54:27 AM

HCPCS code Q0496 and Q0481 are under the list of prospective payment system for hospital inpatient services. According to the American Hospital Association, on the basis of the prospective payment system for hospital inpatient services, payment for the implantation of ventricular assist devices (VAD) is made under Medicare Part A. Supplies and accessories provided in the inpatient setting that are necessary for the VAD to function are included in the Part A payment. When it becomes necessary to replace these accessories and supplies after the patient has been discharged from inpatient care, payment is made under Medicare Part B.

On the other hand, according to the Medicare Physician Fee Schedules, Code Status for both the codes (Q0496 and Q0481) is “E”, means, these two codes are excluded from Physician Fee Schedule by regulation. These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. No RVUs are shown (Facility and Non-Facility is $0.00), and no payment may be made under the fee schedule for these codes. Payment for them, when covered, generally continues under reasonable charge procedures.

However, it was determined by CMS that claims for replacement devices and/or accessories should not be submitted before the lifetime of the item has expired (i.e., 6 or 12 months following discharge of the patient from the hospital or previous payment for a replacement item). This instruction is based on information provided to CMS by the manufacturers that show the lifetime of the battery is 6 months and the lifetime of all other accessories is 1 year. 

CMS will cover replacement supplies and accessories before the lifetime of the item has expired in cases where the item is lost, stolen, or irreparably damaged (i.e., fire, flood, and not wear or deterioration sustained by day-to-day usage). For claims reported in cases where the item is replaced due to being lost, stolen, or irreparably damaged, for replacement and repair should be added to the claim by the hospitals and suppliers. If it is determined by the local carrier or intermediary that the item is reasonable and necessary, then payment for the replacement item can be made.

Hope this helps!

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