Q&A: Understanding transplant billing rules

Wednesday, July 28, 2021

Q: What are some recommended educational resource on billing rules related to transplant services? Education is sought for basics and learning what charges are reported with the transplant encounter vs a separate encounter. The focus is bone marrow transplants (BMT), not organ transplants. I am also trying to learn what types of services for cellular infusions are considered under the same rules as a BMT. Do the same billing rules for donor acquisition charges reported with the BMT transplant recipient claim apply for donor lymphocyte infusions (DLI) when the infused product are allogenic donor cells?

A: The National Marrow Donor Program (NMDP)/Be the Match website has resources that describe the billing rules for allo and auto stem cell and bone marrow transplants. The rules are complex and not intuitive. Medicare requires that all donor search and cell acquisition charges be held and reported on the recipient's transplant claim, which may not occur for months after other services have been rendered to potential donors such as HLA testing/typing, E/M. etc. Recall you can never bill a donor but instead must hang on to all of these charges using the recipient's insurance as the guarantor. You must have these accounts/charges flagged so that when you have the transplant claim they are all brought over and reported using revenue code 815. This is the revenue code required by the NUBC for reporting donor search and cell acquisition charges.

You should also make sure you have line 0077 set up in your cost report. These things really matter now that CMS will provide cost reimbursement for all donor search and cell acquisition costs. This was a huge win that involved Congress passing legislation and CMS enacting new rules/regulations on how it will do this. The first phase of this new way of reimbursing these costs started October 1, 2020, and starting October 1, 2021, the phase-in will be complete. You can also read more about this in CMS' 2021 Inpatient Prospective Payment System final rule, visiting the NMDP/Be the Match website, or the American Society for Transplantation and Cellular Therapy website to find additional free resources. Stem cell transplant billing is very complex and getting it right takes a village.

Editor’s note: This question was answered in the NAHRI Forums. If you have a question, visit the NAHRI Forums and engage with a community of revenue integrity experts.