The contractor takes the following actions to process heart transplant bills. It may
accomplish them manually or modify its MCE and Grouper interface programs to handle
the processing
1. MCE Interface
The MCE creates a Limited Coverage edit for heart transplant procedure codes. Where
these procedure codes are identified by MCE, the contractor checks the provider number
to determine if the provider is an approved transplant center, and checks the effective
approval date. The contractor shall also determine if the facility is certified for adults
and/or pediatric transplants dependent upon the patient’s age. If payment is appropriate
(i.e., the center is approved and the service is on or after the approval date) it overrides the
limited coverage edit.
2. Handling Heart Transplant Billings From Nonapproved Hospitals
Where a heart transplant and covered services are provided by a nonapproved hospital, the
bill data processed through Grouper and Pricer must exclude transplant procedure codes
and related charges.
Stem Cell Transplantation
A. General
Stem cell transplantation is a process in which stem cells are harvested from either a
patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for
intravenous infusion. Autologous stem cell transplantation (AuSCT) is a technique for
restoring stem cells using the patient's own previously stored cells. AuSCT must be used
to effect hematopoietic reconstitution following severely myelotoxic doses of
chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies.
Allogeneic hematopoietic stem cell transplantation (HSCT) is a procedure in which a
portion of a healthy donor's stem cell or bone marrow is obtained and prepared for
intravenous infusion. Allogeneic HSCT may be used to restore function in recipients
having an inherited or acquired deficiency or defect. Hematopoietic stem cells are multipotent
stem cells that give rise to all the blood cell types; these stem cells form blood and
immune cells. A hematopoietic stem cell is a cell isolated from blood or bone marrow that
can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone
marrow into circulating blood, and can undergo programmed cell death, called apoptosis -
a process by which cells that are unneeded or detrimental will self-destruct.
The Centers for Medicare & Medicaid Services (CMS) is clarifying that bone marrow and
peripheral blood stem cell transplantation is a process which includes mobilization,
harvesting, and transplant of bone marrow or peripheral blood stem cells and the
administration of high dose chemotherapy or radiotherapy prior to the actual transplant.
When bone marrow or peripheral blood stem cell transplantation is covered, all necessary
steps are included in coverage. When bone marrow or peripheral blood stem cell
transplantation is non-covered, none of the steps are covered.
Allogeneic and autologous stem cell transplants are covered under Medicare for specific
diagnoses. Effective October 1, 1990, these cases were assigned to MS-DRG 009, Bone
Marrow Transplant.
The A/B MAC (A)'s Medicare Code Editor (MCE) will edit stem cell transplant procedure
codes against diagnosis codes to determine which cases meet specified coverage criteria.
Cases with a diagnosis code for a covered condition will pass (as covered) the MCE
noncovered procedure edit. When a stem cell transplant case is selected for review based
on the random selection of beneficiaries, the QIO will review the case on a post-payment
basis to assure proper coverage decisions
Bone marrow transplant codes that are reported with an ICD-9-CM that is “not otherwise
specified” are returned to the hospital for a more specific procedure code. ICD-10-PCS
codes are more precise and clearly identify autologous and nonautologous stem cells
The A/B MAC (A) may choose to review if data analysis deems it a priority
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