Billing for Allogeneic Stem Cell Transplants - Revenue code 0819

Medical Billing

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1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants

The allogeneic stem cell transplant acquisition charges are and are not for the services, including but not limited to the following costs:

• National Marrow Donor Program 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 related to harvest procedure (eg, general ancillary 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.

Payment for these acquisition services is included in the OPPS APC payment for the allogeneic stem cell transplant when the transplant takes place in the hospital outpatient setting and in the MS-DRG payment for the allogeneic stem cell transplant when the transplant takes place in the inpatient setting.Because the Medicare contractor makes payment for these acquisition services as part of the payment for the allogeneic stem cell transplant (instead of separately), hospitals are permitted to bill and be paid only for additional services furnished and used solely for a Medicare beneficiary, the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. In contrast to the acquisition costs of solid organs for transplant (eg, hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment. Each year, recurring annual updating notices describe changes to and billing instructions for various payment policies implemented in the OPPS.

Acquisition charges apply only to allogeneic transplants (stem cells are provided by a donor other than the recipient) and not to autologous transplants (stem cells are provided by the recipient), where acquisition charges are used to value the donation of stem cells from others to the recipient. In the case of autologous transplants, the hospital may bill the beneficiary and receive payment for all services rendered on behalf of the beneficiary (and not a donor of those stem cells) because the hospice provider may need additional equipment and skilled technical personnel to perform the same services as the remaining hospital services in addition to any free drugs, including clinical labor, that are provided in connection with the stem cell transplant for a beneficiary (refer to Pub. 100-04, chapter 3, §90.3.1 and §231.10 of this chapter regarding billing for autologous stem cell transplants).

2. Billing for Acquisition Services

There are two separate hospital billings and shows acquisition charges for non-directionally related allogeneic stem cell transplants when the patient is inpatient and when the patient is outpatient For instructions on billing for acquisition services for the non-directed allogeneic stem cell transplant that are performed in the inpatient setting, Pub. 100-04, chapter 3, §90.3.1.

For when the allogeneic stem cell transplant is performed outside of the inpatient setting, Stem Cell Acquisition Charges should be reported on FL 42 of Form CMS-1450 (or electronic equivalent) as items separate from the allogeneic bone marrow/stem cell transplant by using code 0819 (Other Organ Acquisition) in block 23 The Revenue Code 0819 should include all services necessary to acquire stem cells from the donor as specified above and should be reported on the same date of service as the transplant to be packaged for payment purposes.

The statement of charges includes the description of services provided, the amount charged, the name of the patient receiving the service (donor/recipient), and listing it as a potential or actual stem cell/bone marrow transplant donor/recipient. The charges have been recorded on the stem cell/bone marrow acquisition cost centre of the transplant hospital. Allogeneic stem cell acquisition service costs incurred in cases that do not result in a transplant because the potential recipient dies subsequent to stem cell collection or other reasons are recorded on the Medicare cost report.

In the hospital outpatient setting for an allogeneic transplant, the hospital would report a ‘transplant’ code as appropriate for the Procedure, and a charge would be recorded against revenue center code 0362 or another appropriate cost centre: selection of the appropriate cost centre is based entirely within the hospital’s purview.

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