evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
 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
(Medicare Claims Processing Manual)
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.   If a beneficiary received a heart transplant from a hospital while it was not an approved facility and later requires services as a result of the noncovered transplant, the services are covered when they are reasonable and necessary in all other respects.   D. - Charges for Heart Acquisition Services   The excising hospital bills the OPO, who in turn bills the transplant (implant) hospital for applicable services.  It should not submit a bill to its contractor.  The transplant hospital must keep an itemized statement that identifies the services rendered , the charges, the person receiving the service (donor/recipient), and whether this person is a potential transplant donor or recipient.  These charges are reflected in the transplant hospital's heart acquisition cost center and are used in determining its standard charge for acquiring a donor's heart.  The standard charge is not a charge representing the acquisition cost of a specific heart; rather, it reflects the average cost associated with each type of heart acquisition.  Also, it is an all inclusive c harge for all services required in acquisition of a heart, i.e., tissue typing, post- operative evaluation, etc.   Acquisition charges shall be billed on a 081X revenue code.  Such charges are not considered for the IPPS outlier calculation when billed for a heart transplant.  E. - Bill Review Procedures
(Medicare Claims Processing Manual)
Acquisition charges shall be billed on a 081X revenue code.  Such charges are not considered for the IPPS outlier calculation when billed for a heart transplant.  E. - Bill Review Procedures   The contractor takes the following actions to process heart transplant bills.  It may accomplish them manually or modify its MCE and Grouper interface programs to handle the processing.  1. MCE Interface   The MCE creates a Limited Coverage edit for heart 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 center, and checks the effect ive 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.  2. Handling Heart Transplant Billings From Nonapproved Hospitals   Where a heart transplant and covered services are provided by a nonapproved hospital, the bill data processed through Grouper and Pricer must exclude transplant procedure codes and related charges.   90.3 - Stem Cell Transplantation  (Rev.11348; Issued: 04- 07-22; Effective: 05 -09-22; Implementation: 05 -09-22)  A. General
(Medicare Claims Processing Manual)
90.3 - Stem Cell Transplantation  (Rev.11348; Issued: 04- 07-22; Effective: 05 -09-22; Implementation: 05 -09-22)  A. General   Stem cell transplantation is a process in which stem cells are harvested from either a patients (autologous) or donors (allogeneic) bone marrow or peripheral blood for intravenous infusion. Autologous stem cell transplantation (AuSCT) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies. Allogeneic hematopoietic stem cell transplantation (HSCT) is a procedure in which a portion of a healthy donor's stem cell or bone marrow is obtained and prepared for intravenous infusion. Allogeneic HSCT may be used to restore function in recipients having an inherited or acquired deficiency or defect.  Hematopoietic stem cells are multi- potent stem cells that give rise to all the blood cell types; these stem cells form blood and immune cells. A hematopoietic stem cell is a cell isolated from blood or bone marrow that can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone marrow into circulating blood, and can undergo programmed cell death, called apoptosis -  a process by which cells that are unneeded or detrimental will self -destruct.   The Centers for Medicare & Medicaid Services (CMS) is clarifying that bone marrow and peripheral blood stem cell transplantation is a process which includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the admi nistration of high dose chemotherapy or radiotherapy prior to the actual transplant.  When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage. When bone marrow or peripheral blood stem cell transplantation is non- covered, none of the steps are covered.   Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. Effective October 1, 1990, these cases were assigned to MS -DRG 009, Bone Marrow Transplant.
(Medicare Claims Processing Manual)
Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. Effective October 1, 1990, these cases were assigned to MS -DRG 009, Bone Marrow Transplant.   The A/B MAC (A)'s Medicare Code Editor (MCE) will edit stem cell transplant procedure codes against diagnosis codes to determine which cases meet specified coverage criteria. Cases with a diagnosis code for a covered condition will pass (as covered) the MC E noncovered procedure edit. When a stem cell transplant case is selected for review based on the random selection of beneficiaries, the QIO will review the case on a post -payment basis to assure proper coverage decisions.  Bone marrow transplant codes that are reported with an ICD -9-CM that is not otherwise specified are returned to the hospital for a more specific procedure code. ICD -10-PCS codes are more precise and clearly identify autologous and nonautologous stem cell s.  The A/B MAC (A) may choose to review if data analysis deems it a priority.  B. Nationally Covered Indications   I. Allogeneic Hematopoietic Stem Cell Transplantation  (HSCT)  a. General    Allogeneic stem cell transplantation ( ICD -10-PCS codes 30230G2,30230G3, 30230Y2, 30230Y3, 30233G2, 30233G3, 30233Y2, 30233Y3, 30240G2, 30240G3, 30240Y2, 30240Y3, 30243G2, 30243G3, 30243Y2, and 30243Y3) is a procedure in which a portion of a healthy donor's stem cells are obtained and prepared for intravenous infusion to restore normal hematopoietic function in recipients having an inherited or acquired hematopoietic deficiency or defect. See Pub. 100- 03, National Coverage Determinations (NCD) Manual, chapt er 1, section 110.23, for further information about this policy, and Pub. 100- 04, chapter 32, section 90, for information on coding.
(Medicare Claims Processing Manual)
Expenses incurred by a donor are a covered benefit to the recipient/beneficiary but, except for physician services, are not paid separately. Services to the donor include physician services, hospital care in connection with screening the stem cell, and ordinary follow -up care.   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   i. Effective for services performed on or after August 1,  1978:   For the treatment of leukemia, leukemia in remission, or aplastic anemia when it is reasonable and necessary;   ii. Effective for services performed on or after June 3,  1985:   For the treatment of severe combined immunodeficiency disease (SCID), and for the treatment of Wiskott- Aldrich syndrome;   iii. Effective for services performed on or after August 4,  2010:   For the treatment of Myelodysplastic Syndromes (MDS) pursuant to Coverage with Evidence Development (CED) in the context of a Medicare - approved, prospective clinical study.  iv. Effective for claims with dates of service on or after January 27,  2016:   1. Allogeneic HSCT for multiple myeloma is covered by Medicare only for beneficiaries with Durie -Salmon Stage II or III multiple myeloma, or International Staging System (ISS) Stage II or Stage III multiple myeloma, and participating in an approved prospective clinical  study.  2. Allogeneic HSCT for myelofibrosis (MF) is covered by Medicare only for beneficiaries with Dynamic International Prognostic Scoring System (DIPSSplus) intermediate -2 or High primary or secondary MF and participating in an approved prospective clinical  study.  3. Allogeneic HSCT for sickle cell disease (SCD) is covered by Medicare only for beneficiaries with severe, symptomatic SCD who participate in an approved prospective clinical  study.  II.  III. Autologous Stem Cell Transplantation  (AuSCT)
(Medicare Claims Processing Manual)
II.  III. Autologous Stem Cell Transplantation  (AuSCT)   a. General   Autologous stem cell transplantation (ICD -10-PCS codes 30230C0, 30230G0, 30230Y0, 30233G0, 30233C0, 30233Y0, 30240C0, 30240G0, 30240Y0, 30243C0, 30243G0, and 30243Y0) is a technique for restoring stem cells using the patient's own previously stored cells. AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (high dose chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies. Refer to Pub. 100- 03, NCD Manual, chapter 1, section 110.23, for further information about this policy, and Pub. 100- 04, chapter 32, section 90, for information on coding.   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:   Acute leukemia in remission who have a high probability of relapse and who have no human leucocyte antigens (HLA) -matched;   Resistant non- Hodgkin's lymphomas or those presenting with poor prognostic features following an initial response;   Recurrent or refractory neuroblastoma; or,   Advanced Hodgkin's disease who have failed conventional therapy and have no HLA -matched donor.  2. Effective for services performed on or after October 1,  2000:
(Medicare Claims Processing Manual)
Recurrent or refractory neuroblastoma; or,   Advanced Hodgkin's disease who have failed conventional therapy and have no HLA -matched donor.  2. Effective for services performed on or after October 1,  2000:   Single AuSCT  is only covered for Durie -Salmon Stage II or III patients that fit the following requirements:   Newly diagnosed or responsive multiple myeloma. 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 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 is reasonable and necessary for Medicare beneficiaries of any age group with primary amyloid light chain (AL) amyloidos is who meet the following criteria:    Amyloid deposition in 2 or fewer organs;  and,  Cardiac left ventricular ejection fraction (EF) greater than 45%.   C. Nationally Non -Covered Indications   I. Allogeneic Hematopoietic Stem Cell Transplantation  (HSCT)  Effective for claims with dates of service on or after May 24, 1996, through January 26, 2016, allogeneic HSCT is not covered as treatment for multiple myeloma. Refer to Pub. 100- 03, NCD Manual, chapter 1, section 110.23, for further information about this  policy, and Pub. 100- 04, chapter 32, section 90, for information on coding.  II. Autologous Stem Cell Transplantation  (AuSCT)   Insufficient data exist to establish definite conclusions regarding the efficacy of AuSCT for the following conditions:
(Medicare Claims Processing Manual)
II. Autologous Stem Cell Transplantation  (AuSCT)   Insufficient data exist to establish definite conclusions regarding the efficacy of AuSCT for the following conditions:   a) Acute leukemia not in  remission;  b) Chronic granulocytic  leukemia;  c) Solid tumors (other than neuroblastoma);  d) Up to October 1, 2000, multiple myeloma;  e) Tandem transplantation (multiple rounds of AuSCT) for patients with multiple  myeloma; f) Effective October 1, 2000, non primary AL amyloidosis;  and, g) Effective October 1, 2000, through March 14, 2005, primary AL amyloidosis for Medicare beneficiaries age 64 or  older.   In these cases, AuSCT is not considered reasonable and necessary within the meaning of  l862(a)(1)(A) of the Act and is not covered under Medicare. Refer to Pub. 100- 03, NCD Manual, chapter 1, section 110.23, for further information about this policy, and Pub. 100- 04, chapter 32, section 90, for information on coding.  D. Other  All other indications for stem cell transplantation not otherwise noted above as covered or non- covered remain at local Medicare Administrative Contractor discretion.    90.3.1 -  Allogeneic  for Stem Cell Transplantation  (Rev. 11113; Issued: 11- 16-21; Effective: 12 -17-21; Implementation: 12 -17-21)   A. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants   1.  Effective for Cost Reporting Periods Beginning Prior to October 1, 2020  Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the  costs of the following services:    National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor;    Tissue typing of donor and recipient;    Donor evaluation;    Physician pre -admission/pre -procedure donor evaluation services;    Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services, etc.);    Post-operative/post -procedure evaluation of donor; and    Preparation and processing of stem cells.