(Medicare Claims Processing Manual)

Local Discretion Covered Diagnosis Codes   C24.0  Malignant neoplasm of extrahepatic bile duct  C7B.02  Secondary carcinoid tumors of liver  D37.6  Neoplasm of uncertain behavior of liver, gallbladder and bile ducts   Nationally NON -Covered Diagnosis Codes   C22.1  Intrahepatic bile duct carcinoma  C22.3  Angiosarcoma of liver  C22.7  Other specified carcinomas of liver  C78.7  Secondary malignant neoplasm of liver and intrahepatic bile duct  C7A.1  Malignant poorly differentiated neuroendocrine tumors  C7A.8  Other malignant neuroendocrine tumors  C7B.8  Other secondary neuroendocrine tumors  D01.5  Carcinoma in situ of liver, gallbladder and bile ducts  D18.00  Hemangioma unspecified site  D18.01  Hemangioma of skin and subcutaneous tissue  D18.02  Hemangioma of intracranial structures  D18.03  Hemangioma of intra -abdominal structures  D18.09  Hemangioma of other sites  D3A.8  Other benign neuroendocrine tumors    The MCE contains a limited coverage edit for liver transplant procedures using ICD - 10-PCS codes, if ICD -10-PCS code is applicable.   0FY00Z0-  Transplantation of Liver, Allogeneic, Open Approach 0FY00Z1- Transplantation of Liver, Syngeneic, Open Approach   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. Contractors shall use c laims data to determine that the coverage criteria specified in Publication 100-03, Section 260.1 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 none of the diagnosiss codes are for a covered condition, or if the provider is not an approved liver transplant facility, the contractor denies the claim.   NOTE: Some noncovered conditions are included in the covered diagnostic codes. (The diagnostic codes are broader than the covered conditions. Do not pay for noncovered conditions.   Grouper  If the bill shows a discharge date before March 8, 1990, the liver transplant procedure is not covered. If the discharge date is March 8, 1990 or later, the contractor processes the bill through Grouper and Pricer. If the discharge date is after March 7, 1 990, and before October 1, 1990, Grouper assigned CMS DRG 191 or 192. The contractor sent the bill to Pricer with review code 08. Pricer would then overlay CMS DRG 191 or 192 with CMS DRG 480 and the weights and thresholds for CMS DRG 480 to price the bill . If the discharge date is after September 30, 1990, Grouper assigns CMS DRG 480 and Pricer is able to price without using review code 08. If the discharge date is after September 30, 2007, Grouper assigns MS -DRG 005 or 006 (Liver transplant with MCC or Intestinal Transplant or Liver transplant without MCC, respectively) and Pricer is able to price without using review code 08.   Liver Transplant Billing From Non -approved Hospitals   Where a liver transplant and covered services are provided by a non- approved hospital, the bill data processed through Grouper and Pricer must exclude transplant procedure codes and related charges.   When CMS approves a hospital to furnish liver transplant services, it informs the hospital of  the effective date in the approval letter. The contractor will receive a copy of the letter   90.5 - Pancreas Transplants Kidney Transplants  (Rev. 3481, Issued: 03- 18-16. Effective: 06-20-16, Implementation: 06-20-16)  A. - Background  Effective July 1, 1999, Medicare covered pancreas transplantation when performed simultaneously with or following a kidney transplant if ICD-9 is applicable, ICD-9- CM procedure code 55.69.  If ICD-10 is applicable, the following ICD-10- PCS codes will be used: 0TY00Z0,  0TY00Z1,  0TY00Z2,  0TY10Z0.  0TY10Z1, and  0TY10Z2.    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 transplantation is sometimes performed on patients with labile diabetes and hypoglycemic unawareness.  Medicare has had a policy of not covering pancreas transplantation.  The Office of Health Technology Assessment performed an assessment on pancreas-kidney transplantation in 1994.  They found reasonable graft survival outcomes for patients receiving either simultaneous pancreas-kidney (SPK) transplantation or pancreas after kidney (PAK) transplantation.  For a list of facilities approved to perform SPK or PAK, refer to the following Web site:  https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf    B. - Billing for Pancreas Transplants   There are no special provisions related to managed care participants.  Managed care plans are required to provide all Medicare covered services.  Medicare does not restrict which hospitals or physicians may perform pancreas transplantation.  The transplant procedure and revenue code 0360 for the operating room are paid under these codes.  Procedures must be reported using the current ICD procedure codes for pancreas and kidney transplants.  Providers must place at least one of the following transplant procedure codes on the claim:   If ICD -9 Is Applicable   52.80  Transplant of pancreas  52.82  Homotransplant of pancreas   The Medicare Code Editor (MCE) has been updated to include 52.80 and 52.82 as limited coverage procedures.  The contractor must determine if the facility is approved for the transplant and certified for either pediatric or adult transplants dependent upon the age of the patient.   Effective October 1, 2000, ICD -9-CM code 52.83 was moved in the MCE to non- covered.  The contractor must override any deny edit on claims that came in with 52.82 prior to October 1, 2000 and adjust, as 52.82 is the correct code.   If the discharge date is July 1, 1999, or later: the contractor processes the bill through Grouper and Pricer.   If ICD -10 is applicable, the following procedure codes (ICD -10-PCS) are:    0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach   0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach   Pancreas transplantation is reasonable and necessary for the following diagnosis codes.  However, since this is not an all -inclusive list, the contractor is permitted to determine if any additional diagnosis codes will be covered for this procedure.   If ICD -9-CM is applicable,  Diabetes Diagnosis Codes and Descriptions   ICD-9-CM Code  Description  250.00  Diabetes mellitus without mention of complication, type II (non -insulin dependent) (NIDDM) (adult onset) or unspecified type, not stated as uncontrolled.  250.01  Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), not stated as uncontrolled.  250.02  Diabetes mellitus without mention of complication, type II (non -insulin dependent) (NIDDM) (adult onset) or unspecified type, uncontrolled.  250.03  Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), 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   NOTE: X=0 -3  If ICD -10-CM is applicable, the diagnosis codes are:  E10.10 -  E10.9   Hypertensive Renal Diagnosis Codes and Descriptions if ICD -9-CM is applicable :   ICD-9-CM Code  Description  403.01  Malignant hypertensive renal disease, with renal failure  403.11  Benign hypertensive renal disease, with renal failure  403.91  Unspecified hypertensive renal disease, with renal failure  404.02  Malignant hypertensive heart and renal disease, with renal failure  404.03  Malignant hypertensive heart and renal disease, with congestive heart failure or renal failure  404.12  Benign hypertensive heart and renal disease, with renal failure  404.13  Benign hypertensive heart and renal disease, with congestive heart failure or renal failure  404.92  Unspecified hypertensive heart and renal disease, with renal failure  404.93  Unspecified hypertensive heart and renal disease, with congestive heart failure or renal failure  585.1 - 585.6, 585.9  Chronic Renal Failure Code   If ICD -10-CM is applicable, diagnosis codes and descriptions are:   ICD-10-CM code  Description  I12.0  Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease  I13.11  Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease  I13.2  Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease  N18.1  Chronic kidney disease, stage 1  N18.2  Chronic kidney disease, stage 2 (mild)  N18.3  Chronic kidney disease, stage 3 (moderate)  N18.4  Chronic kidney disease, stage 4 (severe)  N18.5  Chronic kidney disease, stage 5  N18.6  End stage renal disease  N18.9  Chronic kidney disease, unspecified   NOTE:   If a patient had a kidney transplant that was successful, the patient no longer has chronic kidney failure, therefore it would be inappropriate for the provider to bill ICD -9-CM codes 585.1 -  585.6, 585.9 or, if ICD -10-CM is applicable, the diagnosis codes N18.1 -  N18.9 on such a patient.  In these cases one of the following codes should be present on the claim or in the beneficiary's history.  The provider uses the following ICD -9-CM status codes only when a kidney transplant was performed before the pancreas transplant and ICD -9 is applicable:   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