Billing for Autologous Stem Cell Transplants

The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished. It shows charges for the actual transplant, in revenue center code 0362 or another appropriate cost center. ICD-9-CM or ICD-10-PCS codes are used to identify inpatient procedures.

The HCPCS codes describing autologous stem cell harvesting procedures may be billed and are separately payable under the OPPS when provided in the hospital outpatient setting of care. Autologous harvesting procedures are distinct from the acquisition services described in Pub. 100-04, chapter 4, §231.11 and section A. above for allogeneic stem cell transplants, which include services provided when stem cells are obtained from a donor and not from the patient undergoing the stem cell transplant. The HCPCS codes describing autologous stem cell processing procedures also may be billed and are separately payable under the OPPS when provided to hospital outpatients.

Payment for autologous stem cell harvesting procedures performed in the hospital inpatient setting of care, with transplant also occurring in the inpatient setting of care, is included in the MS-DRG payment for the autologous stem cell transplant.

Autologous Stem Cell Transplantation (AuSCT)

General

 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 (high dose chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies.

If ICD-9-CM is applicable, use the following Procedure Codes and Descriptions

41.01 Autologous bone marrow transplant without purging 

41.04 Autologous hematopoietic stem cell transplant without purging 

41.07 Autologous hematopoietic stem cell transplant with purging 

41.09 Autologous bone marrow transplant with purging

If ICD-10-PCS is applicable, use the following Procedure Codes and Descriptions -

30230AZ Transfusion of Embryonic Stem Cells into Peripheral Vein, Open Approach 

30230G0 Transfusion of Autologous Bone Marrow into Peripheral Vein, Open Approach 

30230Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Open Approach 30233G0 Transfusion of Autologous Bone Marrow into Peripheral Vein, Percutaneous Approach 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach 

30240G0 Transfusion of Autologous Bone Marrow into Central Vein, Open Approach 

30240Y0 Transfusion of Autologous Bone Marrow into Central Vein, Open Approach 

30243G0 Transfusion of Autologous Bone Marrow into Central Vein, Percutaneous Approach 30243Y0 Transfusion of Autologous Hematopoietic Stem Cells into Central Vein, Percutaneous Approach 

Nationally Non-Covered Indications

I. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)

Effective for claims with dates of service on or after May 24, 1996, through January 26, 2016, allogeneic HSCT is not covered as treatment for multiple myeloma. Refer to Pub. 100-03, NCD Manual, chapter 1, section 110.23, for further information about this policy, and Pub. 100-04, chapter 32, section 90, for information on coding.

II. Autologous Stem Cell Transplantation (AuSCT)

Insufficient data exist to establish definite conclusions regarding the efficacy of AuSCT for the following conditions:

a) Acute leukemia not in remission; 

b) Chronic granulocytic leukemia; 

c) Solid tumors (other than neuroblastoma); 

d) Up to October 1, 2000, multiple myeloma; 

e) Tandem transplantation (multiple rounds of AuSCT) for patients with multiple myeloma;

f) Effective October 1, 2000, non primary AL amyloidosis; and, 

g) Effective October 1, 2000, through March 14, 2005, primary AL amyloidosis for Medicare beneficiaries age 64 or older

In these cases, AuSCT is not considered reasonable and necessary within the meaning of §l862(a)(1)(A) of the Act and is not covered under Medicare. 

D. Other

All other indications for stem cell transplantation not otherwise noted above as covered or non-covered remain at local Medicare Administrative Contractor discretion.

Autologous Stem Cell Transplantation (AuSCT)

a. General

Autologous stem cell transplantation (ICD-9-CM Procedure Codes 41.01, 41.04, 41.07, and 41.09; ICD-10-PCS codes 30230AZ, 30230G0, 30230Y0, 30233G0, 30233Y0, 30240G0, 30240Y0, 30243G0, 30243Y0, 30250G0, 30250Y0, 30253G0, 30253Y0, 30260G0, 30260Y0, 30263G0, and 30263Y0) 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 (high dose chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies

b. Covered Conditions

1. Effective for services performed on or after April 28, 1989:

Acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA)-matched; 

Resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response;

Recurrent or refractory neuroblastoma; or, 

Advanced Hodgkin's disease who have failed conventional therapy and have no HLA-matched donor. 

2. Effective for services performed on or after October 1, 2000:

Single AuSCT is only covered for Durie-Salmon Stage II or III patients that fit the following requirements:

 Newly diagnosed or responsive multiple myeloma. This includes those patients with previously untreated disease, those with at least a partial response to prior chemotherapy (defined as a 50% decrease either in measurable paraprotein [serum and/or urine] or in bone marrow infiltration, sustained for at least 1 month), and those in responsive relapse; and  

 Adequate cardiac, renal, pulmonary, and hepatic function