CMS Pub. 100-04, ch. 3, § 90.1.1

There are two basic standard charges that must be developed by transplant hospitals from

costs expected to be incurred in the acquisition of kidneys:

• The standard charge for acquiring a live donor kidney; and

• The standard charge for acquiring a cadaver kidney.

The standard charge is not a charge representing the acquisition cost of a specific kidney;

rather, it is a charge that reflects the average cost associated with each type of kidney

acquisition.

When the transplant hospital bills the program for the transplant, it shows its standard kidney

acquisition charge on revenue code 081X. Kidney acquisition charges are not considered for

the IPPS outlier calculation.

Acquisition services are billed from the excising hospital to the transplant hospital. A billing

form is not submitted from the excising hospital to the FI. The transplant hospital keeps an

itemized statement that identifies the services furnished, the charges, the person receiving the

service (donor/recipient), and whether this is a potential transplant donor or recipient. These

charges are reflected in the transplant hospital's kidney acquisition cost center and are used in

determining the hospital's standard charge for acquiring a live donor's kidney or a cadaver's

kidney. The standard charge is not a charge representing the acquisition cost of a specific

kidney. Rather, it is a charge that reflects the average cost associated with each type of

kidney acquisition. Also, it is an all-inclusive charge for all services required in acquisition

of a kidney, i.e., tissue typing, post-operative evaluation.

A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or Not

Medicare Entitlement Is Established

Tissue typing and pre-transplant evaluation can be reflected only through the kidney

acquisition charge of the hospital where the transplant will take place. The transplant

hospital includes in its kidney acquisition cost center the reasonable charges it pays to the

independent laboratory or other hospital which typed the potential transplant recipient, either

before or after his entitlement. It also includes reasonable charges paid for physician tissue

typing services, applicable to live donors and recipients (during the pre-entitlement period

and after entitlement, but prior to hospital admission for transplantation).

B. - Billing for Blood and Tissue Typing and Other Pre-Transplant Evaluation of Live

Donors

The entitlement date of the beneficiary who will receive the transplant is not a consideration

in reimbursing for the services to donors, since no bill is submitted directly to Medicare. All

charges for services to donors prior to admission into the hospital for excision are "billed"

indirectly to Medicare through the live donor acquisition charge of transplanting hospitals.

C. - Billing Donor And Recipient Pre-Transplant Services (Performed by Transplant

Hospitals or Other Providers) to the Kidney Acquisition Cost Center

The transplant hospital prepares an itemized statement of the services rendered for submittal

to its cost accounting department. Regular Medicare billing forms are not necessary for this

purpose, since no bills are submitted to the A/B MAC (A) at this point.

The itemized statement should contain information that identifies the person receiving the

service (donor/recipient), the health care insurance number, the service rendered and the

charge for the service, as well as a statement as to whether this is a potential transplant donor

or recipient. If it is a potential donor, the provider must identify the prospective recipient.

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 settlement

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 charges 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 to cadavers are

considered Part A hospital services (kidney acquisition costs).

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.