Medicare Coverage for Living Organ Transplant Donors

Coverage

Medicare provides coverage for costs associated with living organ donation. When services are provided for a live organ donor, Medicare considers those services attributable to the Medicare coverage of the organ recipient. These services may include the donor’s preoperative and postoperative care, the removal of the organ, the associated hospital stay and associated services by physicians and surgeons relative to the transplant.

There are a number of ways in which Medicare coverage for organ donors is unique:

• • The organ donor is not responsible for Medicare co-insurance or deductible related to the surgery.
  • Days of inpatient hospital care used by the donor in connection with the organ removal surgery are not counted toward either the donor or recipient Medicare utilization record.
  • Routine donor follow-up care is included in the transplant center’s organ acquisition cost center.
  • Complications that occur with respect to the donor are covered only when directly attributable to the donation surgery.
  • When donor complications occur after the donor’s hospital discharge, care should be billed to the recipient’s health insurance claim number. This rule applies to both facility and physician services.
  • Follow-up donor services by the operating physician are included in the 90-day global payment for the surgery. When services relative to the donation surgery occur after the 90-day global period, they are billed using the recipient’s health insurance claim number.
  • Follow up donor services by a physician other than the operating physician for up to three (3) months after the donation surgery should be billed under the recipient’s health insurance claim number.

Hospital Guidelines

To participate in the Medicare program, a CTC or OPO must be a member of the OPTN. A hospital designated as a CTC is reimbursed for the actual organ transplant based on a DRG and for the reasonable and necessary costs associated with organ acquisition through its MCR.

Before a CTC bills for services to its first living donor, the CTC must establish a Living Donor SAC, which will be used in billing Medicare for the procured organ. This SAC is an average charge developed for each type of organ, by estimating the reasonable and necessary costs expected to be incurred for services furnished to living donors and pre-admission services furnished to recipients of living donor organs during the hospital’s cost reporting period. Details on establishing a SAC may be found in the CMS PRM, Part 1, Chapter 31, Section 3101 A. A link to the PRM is included below under Billing Guidelines.

Physician Guidelines

Payment for physician services to a living donor, when provided in connection with an organ donation to a Medicare beneficiary, is made at 100 percent of the Medicare Part B reasonable charge. These services include the surgery on the donor to excise the organ and care during the inpatient stay. The operating physician’s follow-up services are included in the 90-day global payment for the surgery, and services beyond the 90-day global payment period are billed using the organ recipient’s health insurance claim number.

Billing Guidelines

CMS has updated the PRM with the addition of chapter 31, to provide information on Medicare's payment policy regarding organ acquisition costs. This information was formerly included in chapter 27, sections 2770 through 2775.4. The PRM is referred to as Publication 15-1 and can be found at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html.

Chapter 31 also addresses guidelines for accounting and reporting of costs for KPDs in MCRs. KPDs may occur when a living kidney donor and recipient do not match, and they consent to participate in a KPD matching program that attempts to match the pair with other living donor/recipient pairs, who are often located at different CTCs. A KPD exchange may occur when two or more living donor/recipient pairs match each other.

Please refer to this valuable CMS resource for detailed information on the full spectrum of information associated with organ donation and transplant billing and reimbursement.

Transplant Centers

• • Expenses incurred for routine donor follow-up care are included in the transplant center’s organ acquisition cost center.

Physicians and Surgeons

• • Claims submitted for donor services must include the following:
    • Name, address and HIC number of the recipient.
    • Name and address of the living donor – include this in the documentation record for electronic claims. If submitting a paper claim, enter this information on a separate attachment to the CMS-1500 claim form.
  • Operating Physician: Follow-up services are included in the 90-day global payment for the surgery. Beyond the 90-day global payment period, follow-up services are billed using the recipient’s health insurance claim number.
  • Physician (other than Operating): Follow-up services for up to 3 months following donation surgery should be billed under the recipient’s health insurance claim number.

References

Please refer to the following CMS resources for additional information on this topic:

• • CMS IOM 100-02 (Medicare Benefit Policy Manual) Chapter 11, Section 140
  • MLN Matters® Number: MM7523
    • Related Change Request Number: 7523
    • CMS CR 7523 “Billing for Donor Post-Kidney Transplant Complication Services” October 28, 2011
  • CMS Provider Reimbursement Manual
    • Part 1, Chapter 31 “Organ Donation and Transplant Reimbursement”
  • CMS MLN Matters® Number: SE1608 “Updates to Medicare’s Organ Acquisition and Donation Payment Policy”