Wiki Billing rules for "Wasted" HCPCS

[Sara El Naggar]

A patient underwent cardiac catheterization and the provider has billed for 6 stents (as HCPCS codes C1874 & C17874).
While auditing the medical records, It is mentioned in the operative notes, that 2 stents were damaged during the procedure and they failed to be inserted due to tortuosity Of the vessels; hence they were discarded. Was it correct to claim the damaged stents from the insurer?

 

[thomas7331]

I would assume you are auditing a facility claim in this situation. In most cases and for most payers, payment rates for facility claim are calculated based on reimbursing the average costs to that facility to perform a procedure and/or provide care for a given illness or injury. So generally speaking, it is appropriate for facilities to report any supplies or items that represent a cost that the facility has incurred during the patient's encounter or stay, which would likely be the case here if the facility was not able to re-use or recover their costs for the damaged stents. In most cases, reporting these will not affect the payment on the claim, although the additional costs associated with the incident will count toward calculation of future payment rates.

CMS does published rules for reporting of wasted drugs (with modifier JW, which incidentally also does not change the reimbursement), and for reporting of items that are replaced by the manufacturer at no cost to the facility (FB modifier) but as far as I know, not for other types of items that are wasted. Unless the particular payer's policies or contract stipulates that these may not be billed, I don't think there is any basis for citing this as inappropriate billing by the facility.