CMS Pub. 100-04, ch. 3, § 90.6

A. - Background

Effective for services on or after April 1, 2001, Medicare covers intestinal and multi-visceral

transplantation for the purpose of restoring intestinal function in patients with irreversible

intestinal failure. Intestinal failure is defined as the loss of absorptive capacity of the small

bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel

syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality

and profound morbidity. Multi-Visceral transplantation includes organs in the digestive

system (stomach, duodenum, liver, and intestine). See §260.5 of the National Coverage

Determinations Manual for further information.

B. - Approved Transplant Facilities

Medicare will cover intestinal transplantation if performed in an approved facility. The

approved facilities are located at: https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf

C. - Billing

If ICD-9-CM is applicable, ICD-9-CM procedure code 46.97 is effective for discharges on or

after April 1, 2001. If ICD-10 is applicable, the ICD-10-PCS procedure codes are 0DY80Z0,

0DY80Z1, 0DYE0Z0, and 0DYE0Z1. The Medicare Code Editor (MCE) lists these codes as

limited coverage procedures. The shared system shall override the MCE when this

procedure code is listed and services are provided in an approved transplant facility, and also

determine if the facility is certified for adults and/or pediatric transplants and Return To

Provider (RTP) as appropriate.

For these procedures where the provider is approved as a transplant facility and certified for

the adult and/or pediatric population, and the service is performed on or after the transplant

approval date, contractors shall use claims data to determine that the coverage criteria

specified in Publication 100-03, Section §260.5 have been met.

If payment is appropriate (i.e., the facility is approved, the service is furnished on or after the

approval date, and the beneficiary has a covered condition), the contractor sends the claim to

Grouper and Pricer.

If ICD-9-CM is applicable, charges for ICD-9-CM procedure code 46.97, and, if ICD-10 is

applicable, the ICD-10-PCS procedure codes 0DY80Z0, 0DY80Z1, 0DYE0Z0, or 0DYE0Z1

should be billed under revenue code 0360, Operating Room Services.

For discharge dates on or after October 1, 2001, acquisition charges are billed under revenue

code 081X, Organ Acquisition. For discharge dates between April 1, 2001, and September

30, 2001, hospitals were to report the acquisition charges on the claim, but there was no

interim pass-through payment made for these costs.

Bill the procedure used to obtain the donor's organ on the same claim, using appropriate ICD

procedure codes.

The 11X bill type should be used when billing for intestinal transplants.

Immunosuppressive therapy for intestinal transplantation is covered and should be billed

consistent with other organ transplants under the current rules.

If ICD-9-CM is applicable, there is no specific ICD-9-CM diagnosis code for intestinal

failure. Diagnosis codes exist to capture the causes of intestinal failure. Some examples of

intestinal failure include but are not limited to the following conditions and their associated

ICD-9-CM codes:

• Volvulus 560.2,

• Volvulus gastroschisis 756.79, other [congenital] anomalies of abdominal

wall,

• Volvulus gastroschisis 569.89, other specified disorders of intestine,

• Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,

• Necrotizing enterocolitis 014.8, other tuberculosis of intestines, peritoneum,

and mesenteric,

• Necrotizing enterocolitis and splanchnic vascular thrombosis 557.0, acute

vascular insufficiency of intestine,

• Inflammatory bowel disease 569.9, unspecified disorder of intestine,

• Radiation enteritis 777.5, necrotizing enterocolitis in fetus or newborn, and

• Radiation enteritis 558.1.

If ICD-10-CM is applicable, some diagnosis codes that may be used for intestinal failure are:

• Volvulus K56.2,

• Enteroptosis K63.4,

• Other specified diseases of intestine K63.89,

• Other specified diseases of the digestive system K92.89,

• Postsurgical malabsorption, not elsewhere classified K91.2,

• Other congenital malformations of abdominal wall Q79.59,

• Necrotizing enterocolitis in newborn, unspecified P77.9,

• Stage 1 necrotizing enterocolitis in newborn P77.1,

• Stage 2 necrotizing enterocolitis in newborn P77.2, and

• Stage 3 necrotizing enterocolitis in newborn P77.3.

D. - Acquisition Costs

A separate organ acquisition cost center was established for acquisition costs incurred on or

after October 1, 2001. Therefore, acquisition charges billed on revenue code 081x are

removed from the claim’s total covered charges so as to not be included in the IPPS outlier

calculation. The Medicare Cost Report will include a separate line to account for these

transplantation costs.

For intestinal and multi-visceral transplants performed between April 1, 2001, and October 1,

2001, the DRG payment was payment in full for all hospital services related to this

procedure.

E. - Medicare Summary Notices (MSN), Remittance Advice Messages, and Notice of

Utilization Notices (NOU)

If an intestinal transplant is billed by an unapproved facility after April 1, 2001, the

contractor shall deny the claim.

The following reflects the remittance advice messages and associated codes that will appear

when rejecting/denying claims under this policy. This CARC/RARC combination is

compliant with CAQH CORE Business Scenario 3.

Group Code: CO

CARC: 171

RARC: N/A

MSN: 21.6 or 21.18 or 16.2