There are three key points to keep in mind when billing Medicare:
- Diagnoses, procedures, revenue codes, and billed charges must be added to the claim for Medicare payment, analysis, and future rate-setting.
- Medicare has provided specific guidance on how providers should report all donor-associated services, including search and cell procurement charges.
- Inpatient and outpatient billing rules are basically the same, even though the payment rates vary along with the rate-setting process.
Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor. Acquisition charges do not apply to autologous transplants, but they do apply to both related and unrelated donors for allogeneic transplants.
Donor search and cell procurement must be held until the time of transplant. Transplant centers should keep an itemized statement that identifies the services furnished, the charges, and the person receiving the service (donor or recipient). These charges are not paid for separately but instead are intended to be reflected/bundled into the transplant procedure payment (either the DRG or C-APC). Review the CMS Medicare Claims Processing Manual, 100-4, Chapter 3, Section 90.3.1 (CMS.gov) to learn more.
Use Rev Code 0815 to Report Donor Costs
Acquisition charges are to be reported on the recipient’s bill (inpatient or outpatient) using revenue code 0815, at the time of the transplant (i.e. same date of service). 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/Be The Match fees, if applicable, for stem cells from an unrelated donor
- Tissue typing of donor and recipient
- Donor evaluation
- Physician 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
- Preparation and processing of stem cells
Do Not Bill Donor and Search Costs Separately
For any allogeneic Medicare transplant, you
cannot bill Medicare separately for donor and search costs. All donor
related charges, including donor search and acquisition costs, must be held and
included on the inpatient transplant claim itself using revenue code 0815. The
same rules apply for reporting outpatient donor related charges including
search and acquisition and on outpatient claims, some providers may elect to
report HCPCS/CPT code 38204 along with revenue code 0815 to reflect these
charges. This HCPCS/CPT is not required, but can be used.
Who Pays First (CMS.gov) – How Medicare works with other types of coverage.