Trying to understand CMS reimbursement for organ acquisition and its allowable costs? BESLER’s Director of Reimbursement, Jeff Wolf, answers your questions on how to accurately report organ acquisition charges.
- For the Medicare Ratio in relation to Kidney Living Donors, is the Medicare count in that ratio taken using the donor’s insurance or is it taken from the recipient’s insurance?
The Medicare count is always related to the Recipient. It is the “Recipient’s” insurance that is paying the bill for transplant and acquisition. - Does the proposed rule change the way we accumulate pre-transplant costs for Medicare vs non-Medicare?
No, the types of expenses will still be treated the same, the pre/post time studies will be for all staff serving all transplant patients. The significant change is what organs can be counted for the Medicare usable organs (the numerator). This change will lower the Medicare percentage since only Medicare Organs provided to the OPOs will be able to be included. - How do we count simultaneously organ transplants when Medicare advantage is the payor. This will be for K/P or L/K and what about the evaluation process?
When you know that the recipient is slated for a dual transplant then all of the evaluation services are split between the multiple organs on a percent to total basis. There is some leeway in determining the Percent to total used, but most facilities just use 50/50 or 33/33/33 percentages. - Since a hospital is open 24/7, why can’t you use a week that has a holiday in it for the time studies?
Medicare, specifically, doesn’t want holidays included. They want a consistent application of the time study for all weeks that the time study happens. They want an even distribution. They don’t want to see one day where everyone is off. Medicare requires the time studies to be based on a normal work week. - Do you have to submit time studies to the MAC every year?
Per the regulations yes, you should submit your planned time studies at least 90 days before the FYB. As to the actual time studies, you must perform them each year. During the audit the MAC will be reviewing these time studies for compliance. The MAC will treat all expenses associated with incomplete time studies as Post Transplant. - Is there somewhere to get an actual breakdown of what should be included in the Pre-Transplant for acquisition?
There is no specific list of what is allowable expenses. Medicare relies on the regulation that states “Reasonable and Prudent” to achieve the patient treatment goals. That means that each transplant facility will have slightly different costs associated with their Organ Acquisition activities. As a basic rule, all staff and operating expenses associated with helping a patient process through the evaluation and management phase as well as the cost of identifying , matching, purchasing/excising the organs are part of Organ acquisition. - In terms of transplant charges, every office visit is technically an evaluation, but how do we know what they are evaluating? Do we leverage the diagnosis codes?
We have a clinician review the claim to make sure that he diagnosis, and the treatments are repayed to the evaluation and management of the patient for the expected transplant. The clinitian uses the Dignosis codes as well as the HCPC codes on the claims. - It is being proposed that only OPO organs that go into Medicare patients will be counted as Medicare usable in the future. Has there been discussion as to whom would track which ones eventually are transplanted into Medicare beneficiaries?
CMS stated in the proposed rules that the OPO and the Transplant facilities will be responsible for coordinating this information. - Who pays evaluations for Medicare Advantage covered patients?
The Medicare Advantage plan pays for the Transplant related services for their patients. The only exception to that is now the Medicare Advantage Kidney Transplants are counted in the Medicare usable Organs. - How should a dual transplant for Medicare Advantage patients should be handled (ie: a kidney/pancreas transplant)?
The only difference with a dual transplant is that the service charges for the Recipient will need to be split (al revcodes & all Charges) on a Percent to total basis. Most hospitals use the number of organs as the basis, so 50/50 or 33/33/33 percent.
To listen to Jeff’s “Principles of Organ Acquisition” webinar, click here.
