The contractor takes the following actions to process liver transplant bills.
Operative Report
The contractor requires the operative report with all claims for liver transplants, or sends a
development request to the hospital for each liver transplant with a diagnosis code for a
covered condition.
MCE Interface
The MCE contains a limited coverage edit for liver transplant procedures using ICD-9-
CM code 50.59 if ICD-9 is applicable, and, if ICD-10 is applicable, using ICD-10-PCS
codes 0FY00Z0, 0FY00Z1, and 0FY00Z2.
Where a liver transplant procedure code is identified by the MCE, the contractor shall
check the provider number and effective date to determine if the provider is an approved
liver transplant facility at the time of the transplant, and the contractor shall also determine
if the facility is certified for adults and/or pediatric transplants dependent upon the
patient’s age. If yes, the claim is suspended for review of the operative report to
determine whether the beneficiary has at least one of the covered conditions when the
diagnosis code is for a covered condition. If payment is appropriate (i.e., the facility is
approved, the service is furnished on or after the approval date, and the beneficiary has a
covered condition), the contractor sends the claim to Grouper and Pricer.
