(Medicare Claims Processing Manual)

NOTE: Please note that effective September 30, 2021 PCS codes for Allogeneic SCT 30230G2,  30230G3, 30230Y2, 30230Y3, 30240G2, 30240G3, 30240Y2, 30240Y3 and PCS codes for Autologous SCT 30230C0, 30230G0, 30230Y0, 30240C0, 30240G0, 30240Y0 are end -dated.    B. - Covered Conditions   1. 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 -10-CM is applicable, use the following Diagnosis Codes and Descriptions -   Diagnosis Code  Description  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  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:   If ICD -10-CM is applicable use the following, code ranges C82.01 -  C85.29, C85.81 -  C86.6, C96.4, and C96.Z -  C96.9.  Recurrent or refractory neuroblastoma (see ICD -10-CM codes Neoplasm by site, malignant for the appropriate diagnosis code)   following ranges are reported: C00 -  C96, and D00 -  D09 Resistant non-  Hodgkins lymphomas); or,  Advanced Hodgkin's disease who have failed conventional therapy and have no HLA -matched donor (ICD -10-CM codes C81.01 -  C81.99).  2. Effective for services performed on or after October 1, 2000:   Durie -Salmon Stage II or III that fit the following requirement are covered: Newly diagnosed or responsive multiple myeloma (if ICD -10-CM is applicable, diagnosis codes C90.00, C90.01, C90.02, and D47.Z9). 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.  3. Effective for Services On or After March 15,  2005  Effective for services performed on or after March 15, 2005, when recognized clinical risk factors are employed to select patients for transplantation, high- dose melphalan (HDM), together with AuSCT, in treating Medicare beneficiaries of any age group with  primary amyloid light -chain (AL) amyloidosis who meet the following criteria:   Amyloid deposition in 2 or fewer organs ;  and,   Cardiac left ventricular ejection fraction (EF) of 45% or  greater.   NOTE: Please note that effective April 01, 2022 unspecified ICD -10-DX codes C47.9, C72.50, C72.9, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C85.91, C85.92, C85.93, C85.94, C85.96, C85.97, C85.98, C85.99, C91.91, C92.91, C93.91, C95.91, C96.20, C96.9  are end -dated.   C.  Non -covered Conditions   Insufficient data exist to establish definite conclusions regarding the efficacy of autologous stem cell transplantation for the following conditions:   a)  Acute leukemia not in remission prior to October 1, 2000 ( if ICD -10-CM is applicable, ICD -10-CM codes C91.00, C92.00, C93.00, C94.00, and C95.00)   b) Chronic granulocytic leukemia prior to October 1, 2000 (if ICD -10-CM is applicable, ICD -10-CM code C92.10);   c) Solid tumors prior to October 1, 2000 (other than neuroblastoma) (if ICD -10-CM is applicable, ICD -10-CM codes C00.0  C80.2 and D00.0  D09.9);   d) Multiple myeloma prior to October 1, 2000 (if ICD-10- CM is applicable, ICD -10-CM codes C90.00, C90.01, C90.02 and D47.Z9);  e) Tandem transplantation, on or after October 1, 2000 (if ICD-10- CM is applicable, ICD -10-CM codes C90.00, C90.01, C90.02, and  D47.Z9) ;  f) Non- primary amyloidosis on or after 10/01/00, for all Medicare beneficiaries  g) Primary AL amyloidosis effective October 1, 2000, through March 14, 2005 for Medicare beneficiaries age 64. (if ICD -10-CM is applicable, ICD -10-CM codes E85.4, E85.81, E85.9, and E85.89);                    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).   D. Billing for Autologous Stem Cell Transplantation (AuSCT)  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-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 90.3.1-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 HC PCS 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.  90.4 - Liver Transplants  (Rev. 2513, Issued: 08- 03-12, Effective: 06-21-12, Implementation: 09-04-12)  A.  Background  For Medicare coverage purposes, liver transplants are considered medically reasonable and necessary for specified conditions when performed in facilities that meet specific criteria.  Coverage guidelines may be found in Publication 100-03, Section 260.1.  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 tu mor (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.   To review the current list of approved Liver Transplant Centers, see http://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/Transplant.html  90.4.1 - Standard Liver Acquisition Charge  (Rev. 1, 10- 01-03)  A3-3615.1, A3- 3615.3   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 hos pital 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 all- inclusive charge for all services required in acquisition of a liver, e.g., tissue typing, transportation of organ, and surgeons' retrieval fees.     90.4.2 - Billing for Liver Transplant and Acquisition Services  (Rev.11035, Issued:10- 13-21, Effective: 11 -17-21; Implementation: 11 -17-21)  The inpatient claim is completed in accordance with instructions in chapter 25 for the beneficiary who receives a covered liver transplant. Applicable standard liver acquisition charges are identified separately by revenue code 081X. Where interim bills ar e 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 charge for services furnished directly to the Medicare recipient.  The contractor deducts liver acquisition charges for IPPS hospitals prior to processing through Pricer. Costs of liver acquisition incurred by approved liver transplant facilities are not included in the liver transplant prospective payment. They are paid on a reasonable cost basis. This item is a "pass -through" cost for which interim payments are made. (See the Provider Reimbursement Manual, Part 1, 2802 B.8.) The contractor includes liver acquisition charges under revenue code 081X in the HUIP record tha t it sends to CWF and the QIO.   MCE Interface   The MCE contains a limited coverage edit for liver transplant procedures using below ICD -10-CM codes if ICD-10-CM is applicable.    Nationally Covered Diagnosis Codes   Diagnosis  Code   Description  B16.0  Acute hepatitis B with delta -agent with hepatic coma  B16.1  Acute hepatitis B with delta -agent without hepatic coma  B16.2  Acute hepatitis B without delta -agent with hepatic coma  B16.9  Acute hepatitis B without delta -agent and without hepatic coma