Billing Transplant Services

Medicare Summary Notice (MSN) for Services in Hospitals That Do Not Charge 

Where the hospital does not charge for outpatient services, the A/B MAC (A) does not send the individual an MSN. This avoids confusion and the appearance that the beneficiary is liable for services received.

Billing Transplant Services

Medicare covers the following organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.

On March 30, 2007, the Department of Health and Human Services (DHHS) established a regulation authorizing the survey and certification of organ transplant programs. The Centers for Medicare & Medicaid Services (CMS) is the Federal agency responsible for monitoring compliance with the Medicare conditions of participation. All hospital transplant programs covered by the regulation (does not include stem cell transplants), whether currently approved by CMS or seeking initial approval, must submit a request for approval under the new regulations to CMS by December 26, 2007 (180 days from the effective date of the regulation.)

Kidney Transplant - General

A3-3612, HO-E414

A major treatment for patients with ESRD is kidney transplantation. This involves removing a kidney, usually from a living relative of the patient or from an unrelated person who has died, and surgically placing the kidney into the patient. After the beneficiary receives a kidney transplant, Medicare pays the transplant hospital for the transplant and appropriate standard acquisition charges. Special provisions apply to payment. For the list of approved Medicare certified transplant facilities, refer to the

following Web site: http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage A transplant hospital may acquire cadaver kidneys by: 

 Excising kidneys from cadavers in its own hospital; and 

 Arrangements with a freestanding organ procurement organization (OPO) that provides cadaver kidneys to any transplant hospital or by a hospital based OPO.

A transplant hospital that is also a certified organ procurement organization may acquire cadaver kidneys by:  Having its organ procurement team excise kidneys from cadavers in other hospitals; 

 Arrangements with participating community hospitals, whether they excise kidneys on a regular or irregular basis; and 

 Arrangements with an organ procurement organization that services the transplant hospital as a member of a network.

When the transplant hospital also excises the cadaver kidney, the cost of the procedure is included in its kidney acquisition costs and is considered in arriving at its standard cadaver kidney acquisition charge. When the transplant hospital excises a kidney to provide another hospital, it may use its standard cadaver kidney acquisition charge or its standard detailed departmental charges to bill that hospital. 

When the excising hospital is not a transplant hospital, it bills its customary charges for services used in excising the cadaver kidney to the transplant hospital or organ procurement agency. 

If the transplanting hospital's organ procurement team excises the cadaver kidney at another hospital, the cost of operating such a team is included in the transplanting hospital's kidney acquisition costs, along with the reasonable charges billed by the other hospital of its services.