Billing for Kidney Transplant and Acquisition Services

Applicable standard kidney acquisition charges are identified separately by revenue code 0811 (Living Donor Kidney Acquisition) or 0812 (Cadaver Donor Kidney Acquisition). Where interim bills are submitted, the standard acquisition charge appears on the billing form for the period during which the transplant took place. This charge is in addition to the hospital's charges for services rendered directly to the Medicare recipient. 

The contractor deducts kidney acquisition charges for PPS hospitals for processing through Pricer. These costs, incurred by approved kidney transplant hospitals, are not included in the kidney transplant prospective payment. They are paid on a reasonable cost basis. Interim payment is paid as a "pass through" item. (See the Provider Reimbursement Manual, Part 1, §2802 B.8.) The contractor includes kidney acquisition charges under the appropriate revenue code in CWF

Bill Review Procedures 

The Medicare Code Editor (MCE) creates a Limited Coverage edit for kidney 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. 

Billing for Donor Post-Kidney Transplant Complication Services 

Expenses incurred for complications that arise with respect to the donor are covered and separately billable only if they are directly attributable to the donation surgery.

All covered services (both institutional and professional) for complications from a Medicare covered transplant that arise after the date of the donor’s transplant discharge will be billed under the recipient’s health insurance claim number and are billed to the Medicare program in the same manner as all Medicare Part B services are billed.

 All covered donor post-kidney transplant complication services must be billed to the account of the recipient (i.e., the recipient's Medicare number) 

 Modifier Q3 (Live Kidney Donor and Related Services) appears on each covered line of the claim that contains a HCPCS code.

Institutional claims will be required to also include:

 Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients)

 Patient Relationship Code 39 (Organ Donor)

Contractors shall override Edit 5211 when modifier Q3 appears on claims for donor services it receives when the recipient is deceased 

NOTE: For institutional claims which do not require modifiers, contractors may manually override the CWF edit as necessary.