(Medicare Claims Processing Manual)

When the excising hospital is not a transplant hospital, it bills its customary charges for services used in excising the cadaver kidney to the transplant hospital or organ procurement agency.   If the transplanting hospital's organ procurement team excises the cadaver kidney at another hospital, the cost of operating such a team is included in the transplanting hospital's kidney acquisition costs, along with the reasonable charges billed by the other hospital of its services.   90.1.1 - The Standard Kidney Acquisition Charge  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   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 c harges, 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 s tandard 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 pre -entitlement period and after entitlement, but prior to hospital admission for transplantation).   B. - Billing for Blood and Tissue Typing and Other Pre -Transplant Evaluation of Live Donors   The entitlement date of the beneficiary who will receive the transplant is not a consideration in reimbursing for the services to donors, since no bill is submitted directly to Medicare.  All charges for services to donors prior to admission into the hospi tal for excision are "billed" indirectly to Medicare through the live donor acquisition charge of transplanting hospitals.   C. - Billing Donor And Recipient Pre -Transplant Services (Performed by Transplant Hospitals or Other Providers) to the Kidney Acquisition Cost Center   The transplant hospital prepares an itemized statement of the services rendered for submittal to its cost accounting department.  Regular Medicare billing forms are not necessary for this purpose, since no bills are submitted to the A/B MAC (A) at this point.  The itemized statement should contain information that identifies the person receiving the service (donor/recipient), the health care insurance number, the service rendered and the charge for the service, as well as a statement as to whether this is a potential transplant donor or recipient.  If it is a potential donor, the provider must identify the prospective recipient.   EXAMPLE:   Mary Jones  Health care insurance number  200 Adams St. Anywhere, MS   Transplant donor evaluation services for recipient:   John Jones  Health care insurance number  200 Adams St. Anywhere, MS   Services performed in a hospital other than the potential transplant hospital or by an independent laboratory are billed by that facility to the potential transplant hospital.  This holds true regardless of where in the United States the service is performed.  For example, if the donor services are performed in a Florida hospital and the transplant is to take place in a California hospital, the Florida hospital bills the California hospital (as described in above).  The Florida hospital is paid by the California hospital, which recoups the monies through the kidney acquisition cost center.   D. - 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 s ettlement purposes.   When the tests are performed by an independent laboratory for the excising- only hospital or the transplant hospital, the laboratory bills the hospital that engages its services or the organ procurement agency.  The excising -only hospital includes such char ges in its charges to the transplant hospital, which then includes the charges in developing its standard charge for acquiring the cadaver kidney.  It is the transplant hospitals' responsibility to assure that the independent laboratory does not bill both hospitals.  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.   E. - 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 t o cadavers are considered Part A hospital services (kidney acquisition costs).   F. - 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 (See Publication 100- 02, Chapter 11, Section 80.4).  NOTE:   For institutional claims, contractors may manually override the CWF edit as necessary.   G. - Billing For Physicians' Renal Transplantation Services   To ensure proper payment when submitting a Part B bill for the renal surgeon's services to the recipient, the appropriate HCPCS codes must be submitted, including HCPCS codes for concurrent surgery, as applicable.   The bill must include all living donor physicians' services, e.g., Revenue Center code 081X.   90.1.2 - Billing for Kidney Transplant and Acquisition Services  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   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 c harges 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 cente r, 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 patients 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.   90.1.3 - Billing for Donor Post -Kidney Transplant Complication Services  (Rev. 2334, Issued: 10- 28-11; Effective: Policy Effective date: November 28, 2011; Claims Processing Effective date: April 1, 2012; Implementation: April 2, 2012)   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 donors transplant discharge will be billed under the recipients 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 (See Pub. 100 -02, chapter 11, section 80.4).   NOTE:   For institutional claims which do not require modifiers, contractors may manually override the CWF edit as necessary.  90.2 - Heart Transplants  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD - 10, Implementation: ICD - 10: Upon Implementation of ICD - 10, ASC X12: September, 23 2014)   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 app lication 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.   For a complete list of approved transplant centers, visit: https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf    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 ser vices associated with the transplantation procedure are not covered.