Drugs

If the pancreas transplant occurs after the kidney transplant, immunosuppressive therapy will begin with the date of discharge from the inpatient stay for the pancreas transplant.

Charges for Pancreas Acquisition Services

A separate organ acquisition cost center has been established for pancreas transplantation. The Medicare cost report will include a separate line to account for pancreas transplantation costs. The 42 CFR 412.2(e)(4) was changed to include pancreas in the list of organ acquisition costs that are paid on a reasonable cost basis.

Acquisition costs for pancreas transplantation as well as kidney transplants will occur in Revenue Center 081X. The contractor overrides any claims that suspend due to repetition of revenue code 081X on the same claim if the patient had a simultaneous kidney/pancreas transplant. It pays for acquisition costs for both kidney and pancreas organs if transplants are performed simultaneously. It will not pay for more than two organ acquisitions on the same claim. In addition, the contractor remove acquisition charges prior to sending the claims to Pricer so such charges are not included in the outlier calculation.

Medicare Summary Notices (MSN) and Remittance Advice Messages

If the provider submits a claim for simultaneous pancreas kidney transplantation or pancreas transplantation following a kidney transplant, and omits one of the appropriate diagnosis/procedure codes, the contractor shall reject the claim.

The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy

Group Code: CO 

CARC: B15 

RARC: N/A

MSN: 16.32

Diagnosis Codes and Descriptions

ICD-10-CM code Description 

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease 

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease 

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease 

N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) 

N18.3 Chronic kidney disease, stage 3 (moderate) 

N18.4 Chronic kidney disease, stage 4 (severe)

N18.5 Chronic kidney disease, stage 5 

N18.6 End stage renal disease 

N18.9 Chronic kidney disease, unspecified

NOTE: If a patient had a kidney transplant that was successful, the patient no longer has chronic kidney failure, therefore it would be inappropriate for the provider to bill ICD-9- CM codes 585.1 - 585.6, 585.9 or, if ICD-10-CM is applicable, the diagnosis codes N18.1 - N18.9 on such a patient. In these cases one of the following codes should be present on the claim or in the beneficiary's history.

The provider uses the following ICD-9-CM status codes only when a kidney transplant was performed before the pancreas transplant and ICD-9 is applicable:

ICD-9- CM code Description 

V42.0 Organ or tissue replaced by transplant kidney

V43.89 Organ tissue replaced by other means, kidney or pancreas

Billing for Pancreas Transplants

If ICD-10 is applicable, the following procedure codes (ICD-10-PCS) are:

• 0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach 

• 0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach

Pancreas transplantation is reasonable and necessary for the following diagnosis codes. However, since this is not an all-inclusive list, the contractor is permitted to determine if any additional diagnosis codes will be covered for this procedure.

If ICD-9-CM is applicable, Diabetes Diagnosis Codes and Descriptions

ICD-9- CM Code Description 

250.00 Diabetes mellitus without mention of complication, type II (non-insulin dependent) (NIDDM) (adult onset) or unspecified type, not stated as uncontrolled. 

250.01 Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), not stated as uncontrolled.

250.02 Diabetes mellitus without mention of complication, type II (non-insulin dependent) (NIDDM) (adult onset) or unspecified type, uncontrolled. 

250.03 Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), uncontrolled.

 250.1X Diabetes with ketoacidosis 

250.2X Diabetes with hyperosmolarity 

250.3X Diabetes with coma 

Pancreas Transplants Kidney Transplants

Effective July 1, 1999, Medicare covered pancreas transplantation when performed simultaneously with or following a kidney transplant if ICD-9 is applicable, ICD-9-CM procedure code 55.69. If ICD-10 is applicable, the following ICD-10-PCS codes will be used:

0TY00Z0,

0TY00Z1, 

0TY00Z2,

0TY10Z0. 

0TY10Z1, and

0TY10Z2

Pancreas transplantation is performed to induce an insulin independent, euglycemic state in diabetic patients. The procedure is generally limited to those patients with severe secondary complications of diabetes including kidney failure. However, pancreas transplantation is sometimes performed on patients with labile diabetes and hypoglycemic unawareness.

Medicare has had a policy of not covering pancreas transplantation. The Office of Health Technology Assessment performed an assessment on pancreas-kidney transplantation in 1994. They found reasonable graft survival outcomes for patients receiving either simultaneous pancreas-kidney (SPK) transplantation or pancreas after kidney (PAK) transplantation. For a list of facilities approved to perform SPK or PAK, refer to the following Web site: https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf

Billing for Pancreas Transplants

There are no special provisions related to managed care participants. Managed care plans are required to provide all Medicare covered services. Medicare does not restrict which hospitals or physicians may perform pancreas transplantation.

Liver Transplants

For Medicare coverage purposes, liver transplants are considered medically reasonable and necessary for specified conditions when performed in facilities that meet specific criteria.

Effective for claims with dates of service June 21, 2012 and later, contractors may, at their discretion cover adult liver transplantation for patients with extrahepatic unresectable cholangiocarcinoma (CCA), (2) liver metastases due to a neuroendocrine tumor (NET) or (3) hemangioendothelimo (HAE) when furnished in an approved Liver Transplant Center  (below). All other nationally non-covered malignancies continue to remain nationally non-covered.

Standard Liver Acquisition Charge

Each transplant facility must develop a standard charge for acquiring a cadaver liver from costs it expects to incur in the acquisition of livers.

This standard charge is not a charge that represents the acquisition cost of a specific liver. Rather, it is a charge that reflects the average cost associated with a liver acquisition.

Services associated with liver acquisition are billed from the organ procurement organization or, in some cases, the excising hospital to the transplant hospital. The excising hospital does not submit a billing form to the A/B MAC (A). The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and the potential transplant donor. These charges are reflected in the transplant hospital's liver acquisition cost center and are used in determining the hospital's standard charge for acquiring a cadaver's liver. The standard charge is not a charge representing the acquisition cost of a specific liver. Rather, it is a charge that reflects the average cost associated with liver acquisition. Also, it is an allinclusive charge for all services required in acquisition of a liver, e.g., tissue typing, transportation of organ, and surgeons' retrieval fees.

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. See Pub. 100-04, chapter 4, §231.11 for instructions regarding billing for acquisition services for allogeneic stem cell transplants that are performed in the outpatient setting.

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 0819 (Other Organ Acquisition). Revenue code 0819 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.

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.

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; 

Covered Conditions

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

For acute leukemia in remission for patients who have a high probability of relapse and who have no human leucocyte antigens (HLA)-matched, the following diagnosis codes are reported:

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

Diagnosis Code Description 

204.01 Lymphoid leukemia, acute, in remission 

205.01 Myeloid leukemia, acute, in remission 

206.01 Monocytic leukemia, acute, in remission 

207.01 Acute erythremia and erythroleukemia, in remission 

208.01 Leukemia of unspecified cell type, acute, in remission

If ICD-10-CM is applicable, use the following Diagnosis Codes and Descriptions

C91.01 Acute lymphoblastic leukemia, in remission 

C92.01 Acute myeloblastic leukemia, in remission 

C92.41 Acute promyelocytic leukemia, in remission 

C92.51 Acute myelomonocytic leukemia, in remission 

C92.61 Acute myeloid leukemia with 11q23-abnormality in remission

C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission 

C93.01 Acute monoblastic/monocytic leukemia, in remission 

C94.01 Acute erythroid leukemia, in remission 

C94.21 Acute megakaryoblastic leukemia, in remission 

C94.41 Acute parmyelosis with myelofibrosis, in remission

C95.01 Acute leukemia of unspecified cell type, in remission

For resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response the following diagnosis codes are reported:

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. 

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

Nationally Covered Indications

I. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) 

a. General 

Allogeneic stem cell transplantation (ICD-9-CM Procedure Codes 41.02, 41.03, 41.05, and 41.08,; ICD-10-PCS codes 30230G1, 30230Y1, 30233G1, 30233Y1, 30240G1, 30240Y1, 30243G1, 30243Y1, 30250G1, 30250Y1, 30253G1, 30253Y1, 30260G1, 30260Y1, 30263G1, and 30263Y1) is a procedure in which a portion of a healthy donor's stem cells are obtained and prepared for intravenous infusion to restore normal hematopoietic function in recipients having an inherited or acquired hematopoietic deficiency or defect.

Expenses incurred by a donor are a covered benefit to the recipient/beneficiary but, except for physician services, are not paid separately. Services to the donor include physician services, hospital care in connection with screening the stem cell, and ordinary follow-up care.

b. Covered Conditions

i. Effective for services performed on or after August 1, 1978: 

For the treatment of leukemia, leukemia in remission, or aplastic anemia when it is reasonable and necessary; 

ii. Effective for services performed on or after June 3, 1985: 

For the treatment of severe combined immunodeficiency disease (SCID), and for the treatment of Wiskott-Aldrich syndrome; 

iii. Effective for services performed on or after August 4, 2010: 

For the treatment of Myelodysplastic Syndromes (MDS) pursuant to Coverage with Evidence Development (CED) in the context of a Medicareapproved, prospective clinical study.

Bill Review Procedures

The contractor takes the following actions to process heart transplant bills. It may accomplish them manually or modify its MCE and Grouper interface programs to handle the processing

1. MCE Interface 

The MCE creates a Limited Coverage edit for heart 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.

2. Handling Heart Transplant Billings From Nonapproved Hospitals

Where a heart transplant and covered services are provided by a nonapproved hospital, the bill data processed through Grouper and Pricer must exclude transplant procedure codes and related charges.

Stem Cell Transplantation

A. General 

Stem cell transplantation is a process in which stem cells are harvested from either a patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion. 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 (HDCT) and/or radiotherapy used to treat various malignancies. Allogeneic hematopoietic stem cell transplantation (HSCT) is a procedure in which a portion of a healthy donor's stem cell or bone marrow is obtained and prepared for intravenous infusion. Allogeneic HSCT may be used to restore function in recipients having an inherited or acquired deficiency or defect. Hematopoietic stem cells are multipotent stem cells that give rise to all the blood cell types; these stem cells form blood and immune cells. A hematopoietic stem cell is a cell isolated from blood or bone marrow that can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone marrow into circulating blood, and can undergo programmed cell death, called apoptosis - a process by which cells that are unneeded or detrimental will self-destruct.

Heart Transplants

Cardiac transplantation is covered under Medicare when performed in a facility which is approved by Medicare as meeting institutional coverage criteria. On April 6, 1987, CMS Ruling 87-1, "Criteria for Medicare Coverage of Heart Transplants" was published in the "Federal Register." For Medicare coverage purposes, heart transplants are medically reasonable and necessary when performed in facilities that meet these criteria. If a hospital wishes to bill Medicare for heart transplants, it must submit an application and documentation, showing its ongoing compliance with each criterion.

If a contractor has any questions concerning the effective or approval dates of its hospitals, it should contact its RO.

A. - Effective Dates 

The effective date of coverage for heart transplants performed at facilities applying after July 6, 1987, is the date the facility receives approval as a heart transplant facility. Coverage is effective for discharges October 17, 1986 for facilities that would have qualified and that applied by July 6, 1987. All transplant hospitals will be recertified under the final rule, Federal Register / Vol. 72, No. 61 / Friday, March 30, 2007, / Rules and Regulations.

The CMS informs each hospital of its effective date in an approval letter

B. - Drugs 

Medicare Part B covers immunosuppressive drugs following a covered transplant in an approved facility.

C. - Noncovered Transplants

Medicare will not cover transplants or re-transplants in facilities that have not been approved as meeting the facility criteria. If a beneficiary is admitted for and receives a heart transplant from a hospital that is not approved, physicians' services, and inpatient services associated with the transplantation procedure are not covered. 

If a beneficiary received a heart transplant from a hospital while it was not an approved facility and later requires services as a result of the noncovered transplant, the services are covered when they are reasonable and necessary in all other respects.

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.

Billing for Cadaveric Donor Services

Normally, various tests are performed to determine the type and suitability of a cadaver kidney. Such tests may be performed by the excising hospital (which may also be a transplant hospital) or an independent laboratory. When the excising-only hospital performs the tests, it includes the related charges on its bill to the transplant hospital or to the organ procurement agency.

When the tests are performed by the transplant hospital, it uses the related costs in establishing the standard charge for acquiring the cadaver kidney. The transplant hospital includes the costs and charges in the appropriate departments for final cost settlement purposes.

The cost of these services cannot be billed directly to the program, since such tests and other procedures performed on a cadaver are not identifiable to a specific patient.

Billing For Physicians' Services Prior to Transplantation 

Physicians' services applicable to kidney excisions involving live donors and recipients (during the pre-entitlement period and after entitlement, but prior to entrance into the hospital for transplantation) as well as all physicians' services applicable to cadavers are considered Part A hospital services (kidney acquisition costs).

Billing for Physicians' Services After Transplantation

All physicians' services rendered to the living donor and all physicians' services rendered to the transplant recipient are billed to the Medicare program in the same manner as all Medicare Part B services are billed. All donor physicians' 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 the claim. For services performed on or after January 1, 2011 CWF shall allow Edit 5211 to be overridden at the contractor level. Also, contractors shall override Edit 5211 when this modifier appears on claims for donor services it receives when the recipient is deceased

The Standard Kidney Acquisition Charge

There are two basic standard charges that must be developed by transplant hospitals from costs expected to be incurred in the acquisition of kidneys:

 The standard charge for acquiring a live donor kidney; and

 The standard charge for acquiring a cadaver kidney.

The standard charge is not a charge representing the acquisition cost of a specific kidney; rather, it is a charge that reflects the average cost associated with each type of kidney acquisition.

When the transplant hospital bills the program for the transplant, it shows its standard kidney acquisition charge on revenue code 081X. Kidney acquisition charges are not considered for the IPPS outlier calculation. 

Acquisition services are billed from the excising hospital to the transplant hospital. A billing form is not submitted from the excising hospital to the FI. 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 are reflected in the transplant hospital's kidney acquisition cost center and are used in determining the hospital's standard charge for acquiring a live donor's kidney or a cadaver's kidney. The standard charge is not a charge representing the acquisition cost of a specific kidney. Rather, it is a charge that reflects the average cost associated with each type of kidney acquisition. Also, it is an all-inclusive charge for all services required in acquisition of a kidney, i.e., tissue typing, post-operative evaluation.

A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or Not Medicare Entitlement Is Established  

Tissue typing and pre-transplant evaluation can be reflected only through the kidney acquisition charge of the hospital where the transplant will take place. The transplant hospital includes in its kidney acquisition cost center the reasonable charges it pays to the independent laboratory or other hospital which typed the potential transplant recipient, either before or after his entitlement. It also includes reasonable charges paid for physician tissue typing services, applicable to live donors and recipients (during the preentitlement period and after entitlement, but prior to hospital admission for transplantation).

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.)

Hospitals That Do Not Charge

A3-3660.5 

Participating hospitals that do not charge individuals and also meet the exceptions to the law that normally exclude payment for expenses paid for directly or indirectly by a governmental entity, may be reimbursed the reasonable cost of furnishing covered services to Medicare beneficiaries. The following special procedures apply to their bills. 

Computing Medicare Billing Rate 

The Medicare billing rate per day is determined by the following equation:

Total allowable inpatient cost = cost per day per patient

Total inpatient days

Thus, the billing rate that appears is the average inpatient cost per day per inpatient as calculated from entries on the latest cost settlement report approved by Medicare. Where this is the provider's first year in the program, the A/B MAC (A) determines this rate based on the provider's books and records the appropriate billing rate for services rendered to Medicare beneficiaries.

Computing Medicare Billing Rate (Inpatient) 

The Medicare billing rate is determined in the following manner:

Total available inpatient cost = Cost per day per patient

Total inpatient days 

The A/B MAC (A) multiplies the cost per day per patient by 93 percent for short-term hospitals and by 98 percent for long-term hospitals.  Then it applies the following fixed percentages. The result is the Medicare billing rate.  

Accommodations

Revenue Codes - Codes that identify the accommodations furnished, ancillary services provided or billing calculation are entered in this field. The code indicates whether the rate includes charges for ancillary services or only room and board.

If the patient was furnished more than one type of accommodation, the loops or lines for each type of accommodation are completed. This is necessary whether or not the provider charges an all-inclusive rate according to accommodations.

Where the all-inclusive rate varies with the type of accommodation, the Remarks field is annotated for a five-or-more bed accommodation showing the reason for the accommodation.

Unit of Service - A quantitative measure for services furnished, by revenue category, to or for the patient which includes items such as the number of accommodation days, pints of blood, or renal dialysis treatments, is entered.

Total Charges - The total charges pertaining to the related revenue code for the current billing period is entered.

Noncovered Charges - The total non-covered charges pertaining to the related revenue code for the current billing period is entered.

Ancillary Services

One All-Inclusive Charge Rate - Hospitals with one all-inclusive charge rate, including ancillary services, are reflected in the revenue code. The total charge reflects the charge for both accommodations and ancillary services.

Separate Ancillary All-Inclusive Rate - Some providers segregate charges for ancillary services for billing purposes. Where a separate flat rate charge for ancillary services is incurred either on a daily or total stay basis, the provider enters separate codes for the services. These codes indicate whether the total charge includes only ancillary cost or includes other costs (i.e., blood).

If applicable, the following additional billing instructions are applied:

• Blood

Whenever whole blood is furnished the patient, value codes and amounts are completed. If the all-inclusive rate does not include the charge for whole blood or packed cells, revenue codes, rates, service dates, units, and total charges are completed in the same way a provider not using all-inclusive rates would complete them. When the provider discounts its customary charges for unreplaced blood to which the deductible is applicable, it shows the charges before the discount.