UPMC Health Plan: For Providers: Medicare Expands Ventricular Assist Device Coverage

Medicare has expanded coverage of a ventricular assist device for all Medicare+Choice enrollees who meet established criteria. These devices assist a damaged or weakened heart in pumping blood.

Ventricular assist devices are now covered in these situations:

As a bridge to a heart transplant
For support of blood circulation post-cardiotomy (following open-heart surgery)
For destination therapy (permanent mechanical cardiac support)

The covered use of a ventricular assist device during destination therapy is an addition, or expanded coverage, for Medicare. The expanded coverage applies to services provided on or after October 1, 2003, and through December 31, 2003.

Physicians and hospitals should bill UPMC for Life for these expanded services with the following points in mind:

Billing will be on a fee-for-service basis, even for Medicare patients enrolled in an HMO
UPMC for Life members will pay any applicable coinsurance amounts
There will be no copayments for members for covered use of ventricular assist devices
Physicians will use modifier KZ
Hospitals will use condition code 78
Providers should submit claims after January 1, 2003 (Medicare will not begin processing claims until then)

In 2004, Medicare will implement new capitation rates to cover the cost of this expanded coverage, making the fee-for-service billing no longer necessary.

On November 3, 2003, the University of Pittsburgh Medical Center said in a press release that it has received approval from the Centers for Medicare & Medicaid Services (CMS) to implant ventricular assist systems as destination therapy for heart failure patients who do not qualify for transplantation.

If you have questions or would like more information regarding this procedure, please call the UPMC Health Plan Provider Services Department at 1-877-539-3080.

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