Noncovered Conditions

Insufficient data exist to establish definite conclusions regarding the efficacy of autologous stem cell transplantation for the following conditions:

• Acute leukemia not in remission: 

o If ICD-9-CM is applicable, diagnosis codes 204.00, 205.00, 206.00, 207.00 and 208.00 are noncovered; 

o If ICD-10-CM is applicable, diagnosis codes C91.00, C92.00, C92.40, C92.50, C92.60, C92.A0, C93.00, C94.00, and C95.00 are noncovered. 

• Chronic granulocytic leukemia: 

o If ICD-9-CM is applicable, diagnosis codes 205.10 and 205.11;

o If ICD-10-CM is applicable, diagnosis codes C92.10 and C92.11. 

• Solid tumors (other than neuroblastoma):

o If ICD-9-CM is applicable, diagnosis codes 140.0-199.1; 

o If ICD-10-CM is applicable, diagnosis codes C00.0 - C80.2 and D00.0 - D09.9. 

• Multiple myeloma (ICD-9-CM codes 203.00 and 238.6), through September 30, 2000. 

• Tandem transplantation (multiple rounds of autologous stem cell transplantation) for patients with multiple myeloma 

o If ICD-9-CM is applicable, diagnosis codes 203.00 and 238.6 and,

o If ICD-10-CM is applicable, diagnosis codes C90.00 and D47.Z9) 

• Non-primary (AL) amyloidosis, 

o If ICD-9-CM is applicable, diagnosis code 277.3. Effective October 1, 2000; ICD-9-CM code 277.3 was expanded to codes 277.30, 277.31, and 277.39 effective October 1, 2006. 

o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. or 

• Primary (AL) amyloidosis 

o If ICD-9-CM is applicable, diagnosis codes 277.30, 277.31, and 277.39 and for Medicare beneficiaries age 64 or older, effective October 1, 2000, through March 14, 2005.

o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. 

NOTE: Coverage for conditions other than these specifically designated as covered or non-covered is left to the discretion of the A/B MAC (A).

Billing for Stem Cell Transplantation

 Billing for Allogeneic Stem Cell Transplants

1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services: 

• National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor; 

Billing for Allogeneic Stem Cell Transplants

Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting, and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment. 

Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the hospital may bill and receive payment 

Billing for Acquisition Services 

The hospital bills and shows acquisition charges for allogeneic stem cell transplants based on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished.

When the allogeneic stem cell transplant occurs in the inpatient setting, the hospital identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants separately by using revenue code 0815 (Stem Cell Acquisition). Revenue code 0815 charges should include all services required to acquire stem cells from a donor, as defined above.

On the recipient’s transplant bill, the hospital reports the acquisition charges, cost report days, and utilization days for the donor’s hospital stay (if applicable) and/or charges for other encounters in which the stem cells were obtained from the donor. The donor is covered for medically necessary inpatient hospital days of care or outpatient care provided in connection with the allogeneic stem cell transplant under Part A. Expenses incurred for complications are paid only if they are directly and immediately attributable to the stem cell donation procedure. The hospital reports the acquisition charges on the billing form for the recipient, as described in the first paragraph of this section. It does not charge the donor's days of care against the recipient's utilization record. For cost reporting purposes, it includes the covered donor days and charges as Medicare days and charges.

The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient. These charges will be reflected in the transplant hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell acquisition services in cases that do not result in transplant, due to death of the intended recipient or other causes, hospitals include the costs associated with the acquisition services on the Medicare cost report.

The hospital shows charges for the transplant itself in revenue center code 0362 or another appropriate cost center. Selection of the cost center is up to the hospital.