Description
A ventricular assist device (VAD) is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood. The documentation will be reviewed to determine if initial insertion of a left ventricular assist device (LVAD) was placed for a Medicare-covered indication.
Affected Code(s)
02HA0QZ, 02HA0RJ, 02HA0RS, 02HA0RZ, 02HA3QZ, 02HA3RJ, 02HA3RS, 02HA3RZ, 02HA4QZ, 02HA4RJ, 02HA4RS, 02HA4RZ
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare National Coverage Determinations (NCD) Manual, Chapter 1- Coverage Determinations, §20.9.1 - Ventricular Assist Devices (VADs)
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §320.3-§320.3.2- Ventricular Assist Devices (VADs)
10. AMA CPT Codebook
11. CMS ICD-10 PCS: https://www.cms.gov/medicare/coding-billing/icd-10-codes