(Medicare Claims Processing Manual)

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   If ICD -10-CM is applicable,  the following ICD -10-CM status codes will be used:   ICD-10-CM code  Description  Z48.22  Encounter for aftercare following kidney transplant  Z94.0  Kidney transplant status   NOTE:  If a kidney and pancreas transplants are performed simultaneously, the claim should contain a diabetes diagnosis code and a renal failure code or one of the hypertensive renal failure diagnosis codes.  The claim should also contain two transplant procedur e codes.  If the claim is for a pancreas transplant only, the claim should contain a diabetes diagnosis code and a status code to indicate a previous kidney transplant.  If the status code is not on the claim for the pancreas transplant, the contractor wil l search the beneficiary's claim history for a status code indicating a prior kidney transplant.     C. - 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.  D. - 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.   E. - 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.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: B15  RARC: N/A  MSN: 16.32  If no evidence of a prior kidney transplant is presented, then the contractor shall deny the claim.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 50  RARC: MA126  MSN: 15.4  90.5.1 - Pancreas Transplants Alone (PA)  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  A. - General   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 transpla ntation is sometimes performed on patients with labile diabetes and hypoglycemic unawareness. Medicare has had a long -standing policy of not covering pancreas transplantation, as the safety and effectiveness of the procedure had not been demonstrated. The Office of Health Technology Assessment performed an assessment of pancreas -kidney transplantation in 1994. It found reasonable graft survival outcomes for patients receiving either simultaneous pancreas -kidney transplantation or pancreas -after-kidney trans plantation.   B. - Nationally Covered Indications   CMS determines that whole organ pancreas transplantation will be nationally covered by Medicare when performed simultaneous with or after a kidney transplant. 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.   C. - Billing and Claims Processing   Contractors shall pay for Pancreas Transplantation Alone (PA) effective for services on or after April 26, 2006 when performed in those facilities that are Medicare -approved for kidney transplantation.  Approved facilities are located at the following address:  https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf    Contractors who receive claims for PA services that were performed in an unapproved facility, should reject such claims.    The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO CARC: 58  RARC: N/A  MSN: 16.2   Payment will be made for a PA service performed in an approved facility, and which meets the coverage guidelines mentioned above for beneficiaries with type I diabetes.   All-Inclusive  List of Covered Diagnosis Codes for PA if ICD-9- CM is applicable   (NOTE:  X = 1 and 3 only)  ICD-9-CM code  Description  250.0X  Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), not stated as uncontrolled.  250.1X  Diabetes with ketoacidosis  250.2X  Diabetes with hyperosmolarity  250.3X  Diabetes with coma  250.4X  Diabetes with renal manifestations  250.5X  Diabetes with ophthalmic manifestations  250.6X  Diabetes with neurological manifestations  250.7X  Diabetes with peripheral circulatory disorders  250.8X  Diabetes with other specified manifestations  250.9X  Diabetes with unspecified complication   If ICD -10-CM is applicable,  , the provider uses the following range of ICD-10- CM codes:   E10.10  E10.9.  Procedure Codes   If ICD -9 CM is applicable   52.80 -  Transplant of pancreas  52.82 -  Homotransplant of pancreas   If ICD -10 is applicable, the provider uses the following ICD -10-PCS codes:   0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach  0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach   Contractors who receive claims for PA that are not billed using the covered diagnosis/procedure codes listed above shall reject such claims. The MCE edits to ensure that the transplant is covered based on the diagnosis. The MCE also considers ICD -9-CM code s 52.80 and 52.82 and ICD-10-PCS codes 0FYG0Z0 and 0FYG0Z1 as limited coverage dependent upon whether the facility is approved to perform the transplant and is certified for the age of the patient.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 50  RARC: N/A  MSN: 15.4   Contractors shall hold the provider liable for denied\ rejected claims unless the hospital issues a Hospital Issued Notice of Non- coverage (HINN) or a physician issues an Advanced Beneficiary Notice (ABN) for Part -B for physician services.  D. - Charges for Pancreas Alone 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 PA in the list of organ acquisition costs that are paid on a reasonable cost basis.   Acquisition costs for PA transplantation are billed in Revenue Code 081X.  The contractor removes acquisition charges prior to sending the claims to Pricer so such charges are not included in the outlier calculation.  90.6 - Intestinal and Multi- Visceral Transplants  (Rev. 10210, Issued: 07- 10-2020, Effective: 08 -10-2020, Implementation: 08- 10-2020)   A. - Background   Effective for services on or after April 1, 2001, Medicare covers intestinal and multi -visceral transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure. Intestinal failure is defined as the loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality and profound morbidity. Multi -Visceral transplantation includes organs in the digestive system (stomach, duodenum, liver, and intestine). See 260.5 of the National Coverage Determinations Manual for further infor mation.   B. - Approved Transplant Facilities   Medicare will cover intestinal transplantation if performed in an approved facility. The approved facilities are located at:  https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf    C. - Billing   If ICD -9-CM is applicable, ICD-9-CM procedure code 46.97 is effective for discharges on or after April 1, 2001.  If ICD-10 is applicable, the ICD-10-PCS procedure codes are 0DY80Z0, 0DY80Z1, 0DYE0Z0, and 0DYE0Z1.  The Medicare Code Editor (MCE) lists these codes as limited coverage procedures.  The contractor shall override the MCE when this procedure code is listed and the coverage criteria are met in an approved transplant facility, and also determine if the facility is certified for adults and/or pediatr ic transplants dependent upon the patients age.   For these procedures where the provider is approved as a transplant facility and certified for the adult and/or pediatric population, and the service is performed on or after the transplant approval date dependent on patients age, contractors shall use cl aims data to determine that the coverage criteria specified in Publication 100-03, Section 260.5 have been met.    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.  If ICD -9-CM is applicable, charges for ICD -9-CM procedure code 46.97, and, if ICD-10 is applicable, the ICD -10-PCS procedure codes 0DY80Z0, 0DY80Z1, 0DYE0Z0, or 0DYE0Z1 should be billed under revenue code 0360, Operating Room Services.  For discharge dates on or after October 1, 2001, acquisition charges are billed under revenue code 081X, Organ Acquisition. For discharge dates between April 1, 2001, and September 30, 2001, hospitals were to report the acquisition charges on the claim, but there was no interim pass -through payment made for these costs.  Bill the procedure used to obtain the donor's organ on the same claim, using appropriate ICD procedure codes.   The 11X bill type should be used when billing for intestinal transplants.  Immunosuppressive therapy for intestinal transplantation is covered and should be billed consistent with other organ transplants under the current rules.  If ICD -9-CM is applicable, there is no specific ICD-9-CM diagnosis code for intestinal failure. Diagnosis codes exist to capture the causes of intestinal failure. Some examples of intestinal failure include but are not limited to the following conditions a nd their associated ICD-9-CM codes:    Volvulus 560.2,   Volvulus gastroschisis 756.79, other [congenital] anomalies of abdominal wall,    Volvulus gastroschisis 569.89, other specified disorders of intestine,    Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,   Necrotizing enterocolitis 014.8, other tuberculosis of intestines, peritoneum, and mesenteric,    Necrotizing enterocolitis and splanchnic vascular thrombosis 557.0, acute vascular insufficiency of intestine,    Inflammatory bowel disease 569.9, unspecified disorder of intestine,    Radiation enteritis 777.5, necrotizing enterocolitis in fetus or newborn, and    Radiation enteritis 558.1.  If ICD -10-CM is applicable, some diagnosis codes that may be used for intestinal failure are:    Volvulus K56.2,   Enteroptosis K63.4,