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:
Full Answer
How do hospitals get reimbursed for organ transplants?
Medicare Reimbursement Basics. If approved, the hospital then becomes a certified transplant center for those organs. Medicare reimbursement occurs through three main channels: diagnostic related groups (DRGs) paid to the hospital, organ acquisition cost centers (OACC) paid to the hospital, and physician reimbursement.
How do you bill for a kidney donation?
Billing for Kidney Acquisition (Live Donor and Cadaver Donor): Transplant Hospital Use type of bill (TOB) 11X. Provide the standard kidney acquisition charge on revenue code 081X. For charges from the excising hospital, keep an itemized statement that identifies: Services furnished
Does Medicare Part B cover organ transplants?
Organ transplants Medicare Part B (Medical Insurance) covers: Doctors’ services associated with heart, lung, kidney, pancreas, intestine, and liver organ transplants under certain conditions, but only in Medicare‑certified facilities Bone marrow and cornea transplants under certain conditions
How does CGS bill for organ donation surgery?
When procedure code 55.69 is billed, CGS checks the provider number to determine whether the provider is an approved transplant center and checks the effective approval date. These charges are covered and separately billable only if they are directly attributable to the donation surgery.
What are Medicare usable organs?
Medicare usable organs include Medicare primary transplants, organs sent to the Organ Procurement Organization ( OPO ), organs sent to other CTCs such as through kidney paired donation and children’s hospitals for adult to children live donation, and Medicare secondary payer organs where Medicare had a liability if primary.
Which is the largest payer for organ acquisition costs?
Medicare is the single largest payer for organ acquisition costs but only reimburses for its share of costs.
Is there a risk of over reporting on Medicare reimbursement?
With cost-based reimbursement, there is financial risk with over-reporting as well as under-reporting organ acquisition costs claimed for Medicare reimbursement. Without adequate controls and systems for appropriate documentation, there is an increased risk of non-compliance with CMS regulations and guidelines. Prior Office of Inspector General (OIG) audits noted that transplant centers stated they lacked awareness and understanding of Medicare requirements or had inadvertently claimed non-allowable costs on the Medicare Cost Report.
Does Medicare reimburse usable organs?
Medicare reimburses its share based on the ratio of Medicare usable organs to total usable organs for the specific organ type. Therefore, properly identifying Medicare and total usable organs is critical for appropriate Medicare reimbursement. Medicare usable organs include Medicare primary transplants, organs sent to the Organ Procurement Organization ( OPO ), organs sent to other CTCs such as through kidney paired donation and children’s hospitals for adult to children live donation, and Medicare secondary payer organs where Medicare had a liability if primary. Common errors include not confirming as Medicare primary through EOBs, not testing for Medicare secondary eligibility, and excluding organs sold to the OPO and other CTCs.
What is kidney transplant?
Kidney transplantation is a major treatment for patients with End Stage Renal Disease (ESRD). This involves removing a kidney, usually from a living relative of the patient or from an unrelated person who has died, and surgically implanting the kidney into the patient. After the beneficiary receives a kidney transplant, ...
What is an interim bill?
For interim bills: submit the standard acquisition charge 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. Interim payment is paid as a "pass through" item.
What are the risks of a donor?
There are inherent risks to any surgical procedure, and living donors may experience pain, bleeding, blood clots, infection, and wound complications. Some donors also face mental health issues, such as anxiety or depression, after surgery. Donors should communicate any physical or emotional stress during a follow up appointment.
Can you donate kidneys?
Although a kidney is the most frequently donated organ, people can also potentially donate one of two lobes of the liver, a lung, or part of a lung, the pancreas, or the intestines. Live donors can also give blood, skin, or bone marrow for someone in need.
What is Medicare balance billing?
The Medicare Balance Billing Program works to protect Medicare beneficiaries from being billed by health care practitioners for amounts beyond those approved by Medicare. The program investigates complaints and takes action against those practitioners who violate the law.
Can Medicare be billed above the Medicare reimbursement rate?
When Medicare is the secondary insurer, the health care practitioner may pursue full reimbursement under the terms and conditions of the primary insurer, but the Medicare beneficiary cannot be balance billed above the Medicare reimbursement rate for a Medicare-covered service or supply. "Balance billing" does not include charging ...
What is Ohio Medicaid policy?
Ohio Medicaid policy is developed at the federal and state level. It guides how we operate our programs and how we regulate our providers. This page contains resources for the Ohio Medicaid provider community, including policy and advisory letters, billing guidance, Medicaid forms, research, and reports.
Is Ohio Medicaid changing?
Ohio Medicaid is changing the way we do business. We are redesigning our programs and services to focus on you and your family. The changes we make will help you more easily access information, locate health care providers, and receive quality care.
How does Medicare determine if an organ is usable?
If a Medicare beneficiary has a primary health insurance coverage other than Medicare, determining whether an organ will be counted as a Medicare usable organ depends on the amount paid by the primary insurance. A provider must submit a bill to Medicare when payment from the primary payer is insufficient to cover the entire cost of a transplant including the DRG and the organ acquisition costs. However, when the primary insurance requires the acceptance of their payment in full, a bill is not required, because under the contractual agreement, Medicare has no lia bility because the primary payer has made the payment in full. Accordingly, the organ under the paid in full contractual agreement will not be counted as a Medicare usable organ.
What is total organ acquisition cost?
Total organ acquisition costs are accumulated by organ type on the applicable cost report. A ratio of Medicare usable organ s to total usable organs is applied to the total organ acquisition costs in determining Medicare's share of expenses. This ratio includes only usable organs, but total organ acquisition costs include the cost of organs that are determined to be unusable as Medicare continues to share in these costs.
What percentage of hospitals must have an OPO?
An OPO must have a written agreement with 95 percent of the Medicare and Medicaid participating hospitals and critical access hospitals in its service area that have both a ventilator and an operating room and have not been granted a waiver by CMS to work with another OPO.
How many kidneys does CTC A count?
CTC A counts two Medicare usable kidneys: 1) Donor A’s kidney procured and sent to CTC C and 2) Donor C’s kidney procured by CTC C and received and transplanted by CTC A.
How many CTCs are there for kidney transplants?
There are four CTCs; each with a potential transplant recipient in need of a kidney and each recipient has a willing, but poorly matched, donor. Each recipient and donor pair has been evaluated at their respective CTC.
What are outpatient costs for CTC?
Outpatient Costs.--Included in the CTC’s organ acquisition costs are hospital services classified as outpatient and applicable to a potential organ transplant. These outpatient services include donor and recipient work-ups furnished prior to admission and costs of services rendered by interns and residents not in an approved teaching program. These costs would otherwise be paid under Part B of the Program. Because such costs are applicable to organ acquisitions which are predominantly cadaveric donor related and incurred without an identifiable beneficiary, the services are not billed to a beneficiary when the services are rendered but are included in the CTC’s organ acquisition cost center.
Does Medicare require a donor hospital to be an OPTN?
Medicare does not require that donor hospitals belong to the OPTN. However, a donor hospital must always notify, in a timely manner, the designated OPO of any deaths or imminent deaths in its hospita l. The contacted OPO will implement its donation protocol and, when appropriate, will procure any available organs. When the donor hospital incurs expenses for services authorized by the OPO, the donor hospital bills its customary charges for the services furnished to the OPO to receive payment. Negotiated rates between the OPO and the donor hospital are an acceptable payment methodology but must be reasonable.
What is Medicare Balance Billing Program?
The Medicare Balance Billing Program works to protect Medicare beneficiaries from being billed by health care practitioners for amounts beyond those approved by Medicare. The program investigates complaints and takes action against those practitioners who violate the law.
Do you need a copy of a bill for alleged balance billing?
You will need copies of the various statements and bills showing the itemized billing and denial codes for each instance of alleged balance billing.
How does Medicare bill for transplants?
For a hospital to bill Medicare for transplant services, it must first apply for certification for each organ it proposes to transplant. If approved, the hospital then becomes a certified transplant center for those organs. Medicare reimbursement occurs through three main channels: diagnostic related groups (DRGs) paid to the hospital, organ acquisition cost centers (OACC) paid to the hospital, and physician reimbursement.
When did Medicare start covering kidney transplants?
Reimbursement for chronic hemodialysis and kidney transplantation was scarce until the mid-1960s and haphazard until 1972, when Congress amended the Social Security Act to include coverage for end-stage renal disease for qualified patients. Because the amendment made Medicare the primary kidney transplantation insurer for more than 90% of the United States population, it was Congress and the U.S. Department of Health and Human Services, rather than the commercial health insurance industry, that wrote the rules and accounting practices for kidney transplantation. As transplantation of heart, lung, liver, pancreas, and intestine evolved, the rules and accounting practices applicable to the kidney were extended to other transplantable organs.
What is a DRG in Medicare?
Diagnostic related groups (DRGs) define the payment a hospital receives for the organ transplant itself. First implemented in 1983 in a federal attempt to control escalating Medicare costs, DRGs were used to categorize patients for billing purposes. The introduction of DRGs marked the shift from a reimbursement system based on retrospective charges (after the delivery of care) to one based on "prospective" payment. This meant that hospitals would receive compensation for a patient's care based on the qualifying DRG instead of services provided. In other words, Medicare provides the same reimbursement for each diagnosis regardless of how complex the case or high-risk the patient.
How is total DRG calculated?
Total DRG payment is derived from a calculation involving several factors: a national standard amount, a local wage index, and DRG weight, which weighs diagnoses against each other in terms of resource consumption. For example, a DRG with a weight of 3 would be expected to consume twice the resources of one at 1.5. The national standard amount is divided into a labor-related portion and a nonlabor portion, and a formula exists for annual inflation index adjustment.
How many DRGs are there per patient?
Only one DRG is assigned per patient admission, but certain circumstances or institutions may be eligible for rate adjustments or new DRGs. For instance, additional costs for managing complications during the initial hospitalization are expected to be covered by the DRG payment. If the patient is discharged and readmitted because of a medical problem such as rejection, the hospital is assigned a new DRG for the patient. Some transplant centers may be eligible for potential adjustments to DRG payment rates if they are part of a teaching hospital, where payments may consider factors such as graduate medical education (GME) costs and indirect medical education (IME) costs. Certain teaching institutions also may be eligible for disproportionate share (DSH) adjustments, which approximate the higher costs associated with treating indigent patients, the special need for translators, social services, higher security costs, and other related