(Medicare Benefit Policy Manual)

140.8 - Kidney Recip ient Admitted for Transplantation and Evaluation  (Rev. 1, 10- 01-03)  A3-3178.8, RDF -233.4   When the medical evaluation for a transplant is performed on the recipient or the living donor during the same inpatient stay in which the actual transplant occurs, all such services will be billed, and the costs will be accumulated in the normal manner.  For example, all hospital services rendered to the donor will be considered kidney acquisition services.  However, all physicians services rendered to the living donor and all hospital and physicians services rendered to the recipient will be billed in the same manner as any other inpatient services on the account of the recipient.      140.9  Post-transplant Services Provided to Live Donor  (Rev. 257, Issued: 03- 01-19, Effective: 04 - 01-19 Implementation: 04-  01-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the  Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The donor of an organ fo r a Medicare transplant beneficiary is covered for an unlimited number of days of care in connection with the organ removal operation.  Days of inpatient hospital care used by the donor in connection with the organ removal operation shall not be charged ag ainst either partys utilization record.  However, the programs assumption of liability is limited to those donor expenses that are incurred directly in connection with the organ donation.  Coverage of organ donor services includes postoperative recovery services directly related to the organ donation.  For routine follow -up care the period of postoperative recovery ceases when the donor no longer exhibits symptoms related to the kidney donation.  Claims for services rendered more than 3 months after donat ion surgery will be reviewed.  However, follow -up examinations may be covered up to 6 months after the donation to monitor for possible complications.  The requirement that additional payment cannot be made for services included in the donors organ remova l charge still applies.   Regarding donor follow -up:  Expenses incurred by the transplant center for routine donor follow -up care are included in the transplant centers organ acquisition cost center.  Follow -up services performed by the operating physician  are included in the 90- day global payment for the surgery.  Beyond the 90 -day global payment period, follow -up services are billed using the recipients Medicare beneficiary identifier .  Follow -up services billed by a physician other than the operating physician for up to 3 months following donation surgery should be billed under the recipients Medicare beneficiary identifier .  Regarding donor complications:   Expenses incurred for complic ations that arise with respect to the donor are covered only if they are directly attributable to the donation surgery.  Complications that arise after the date of the donors discharge will be billed under the recipients Medicare beneficiary identifier .  This is true of both facility cost and physician services.  Billings for donor complications will be reviewed.    In all of these situations, the donor is not responsible for co- insurance or deductible.   140.10 - Coverage After Recipient Has Exhausted Part A  (Rev. 1, 10- 01-03)  A3-3178.11   If the recipient has exhausted Part A benefits while the donor still requires and receives inpatient hospital care, the program continues to pay for such donor care under Part A at 100 percent reimbursement.  140.11 - Cada ver Kidneys  (Rev. 1, 10- 01-03)  A3-3178.12   Costs incurred by the provider in connection with the acquisition of a cadaver kidney are reimbursable by the program through the kidney acquisition cost center.  Typical covered costs involved in excising the ca daver kidney include: surgeons service, operating room, anesthetist, donor evaluation and support, preservation supplies (perfusion materials and equipment), preservation technician, telephone consultation charge, intensive care costs, pathology, central supply costs, organ transportation costs, and transportation costs for a technician.  There is no provision in the law for coverage of charges by an agent transporting a kidney for transplant into an eligible beneficiary, if the agent bills the program or the patient directly.  However, reimbursement may be made to hospitals and included in kidney acquisition costs.   140.12 - Services Involved  (Rev. 1, 10- 01-03)  A3-3178.13, RDF -232  When there is no suitable living donor, a patient with renal failure may be considered for a cadaveric transplant.  In such cases, the services provided to recipients of live donor kidneys (i.e., tissue typing and other related tests) are also provided to potential recipients of cadaver kidneys.  However, because a kidney may  not be available for a long period of time, additional services may be provided in the form of direct physician care for the patients renal condition, and certain tests may be performed on a regular basis to allow the physician to have current informatio n regarding the status of the patient and his or her suitability for transplant.  In addition, the number of mixed lymphocyte cultures which are prepared whenever a kidney is procured that may suit the recipient depends on the number of kidneys which becom e available for transplant.  The cost of registering a potential recipient with a kidney transplant registry is also covered, as well as the services furnished to maintain organ viability after excision, i.e., preservation, and transporting the kidney to t he place of transplantation.   140.13 - Tissue Typing Services for Cadaver Kidney  (Rev. 1, 10- 01-03)  A3-3178.14   Tissue typing services for cadaveric kidney recipients are treated in a similar manner to the way in which such services are covered and reimbursed in live donor cases.  Tissue typing of the cadaveric organ by the excising hospital becomes an organ acquisition cost that is included in the charges for organs, which are supplied by the hospital.  140.14 - Cadaver Excision Yielding Two Kidneys  (Rev . 1, 10- 01-03)  A3-3178.15   When two kidneys are obtained from a cadaver, and both kidneys are shipped to the same transplant hospital or organ procurement agency, the hospital should adjust its normal charges to reflect any increased perfusion, preservati on, and shipping costs due to the additional kidney.  On the other hand, when the kidneys are sent to separate organizations or transplant hospitals, the excising hospital should prorate its charges to the receiving organizations so that the total charges do not exceed the amount that would have been billed if one transplant hospital or agency had received both kidneys.   140.15 - Provider Costs Related to Cadaver Kidney Excisions  (Rev. 1, 10- 01-03)  A3-3178.16   Typical provider costs involved in excising a cadaver kidney whether or not it is eventually transplanted include:    Intensive care costs;    Surgeons services -  anesthetist services, operating room, preservation supplies (perfusion materials and equipment), preservation technicians services, donor evaluation and support, pathology, central exchange costs (transportation and packaging), and administration costs (overhead items).  140.16 - Noncovered Transplant Related Items and Services  (Rev. 1, 10- 01-03)  A3-3178.17   The following list represents so me of the transplant related items and services which are not covered and for which no program payment can be made:     Travel, room, and board expenses incurred by a live donor;    Travel, room, and board expenses (to any transplant center) incurred by the recipient;    Reimbursement for the kidney itself when the live donor or the cadaver donors next of kin sells the kidney;    Transportation of the potential cadaveric donor to the transplant hospital (only transportation of the organ is reimbursable as part of t he organ procurement charge); or    Pronouncement of death and burial expenses for the cadaveric donor.   140.17 - Other Covered Services  (Rev. 1, 10- 01-03)  A3-3178.18   A.  Tissue Typing   Tissue typing of the recipient, as well as tissue typing and tests to determine the suitability of a living donor or a cadaveric kidney, are covered as medical expenses, necessary for the treatment of an eligible recipient.  The costs of these services are covered under the hospital insurance or medical insurance programs (P art B coverage after recipient has exhausted Part A), and are reflected in the kidney acquisition costs.  B.  Preservation Laboratories   The services performed by preservation laboratories are medically necessary for the treatment of a beneficiarys illness.  A participating hospital is reimbursed for the reasonable cost of such services which its own laboratory performs or which the hospital purchases from a freestanding preservation laboratory or organ procurement agency.   C.  Registration Fees   A participating hospital which expects to perform a kidney transplant will be reimbursed for the reasonable cost incurred in listing the patient and the patients blood characteristics with a professionally recognized organization that maintains a registry of  potential transplant candidates, and which provides a regular listing of such patients to hospitals engaged in kidney procurement.   140.18 - Hospitals that Excise but Do Not Transplant Kidneys  (Rev. 1, 10- 01-03)  A3-3178.19, PR 1- 2772    The excising hospit al plays an important part in the national organ procurement effort.  Most of these hospitals are community hospitals and neither excise kidneys on a regular basis nor perform transplants.  A hospital that excises but does not transplant kidneys must be certified to participate in the Medicare program.  Where the hospital is not participating in the Medicare program, organs may be accepted from it only if they cannot be obtained from any other source.   A hospital that excises but does not transplant kidneys  may perform excisions on cadavers or on live donors; however, regardless of the vital status of the donor, most of the hospital services utilized in the excision are the same.      Transmittals Issued for this Chapter    Rev #  Issue Date  Subject  Impl Date  CR#  R257BP  03/01/2019 Update to Publication 100- 02 Provide Language -Only Changes for the New Medicare Card Project  04/01/2019  11170  R254BP  12/13/2018 Implementation of Changes in the End -Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2019