Sunday, 19 November 2017

Bill Review Procedures

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.

Monday, 13 November 2017

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.

Tuesday, 7 November 2017

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.

Wednesday, 1 November 2017

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; 

Thursday, 26 October 2017

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:

Saturday, 21 October 2017

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 

Monday, 16 October 2017

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. 

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