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August 13, 2013

Kidney Transplants: Billing Requirements and Organ Donor Charges

Kidney transplantation is a major treatment for patients with End Stage Renal Disease (ESRD). This involves removing a kidney, usually from a living relative of the patient or from an unrelated person who has died, and surgically implanting the kidney into the patient. After the beneficiary receives a kidney transplant, Medicare pays the transplant hospital for the transplant and appropriate standard acquisition charges.

Excision of Cadaver Kidney

  • When the excising hospital is not a transplant hospital, it bills its customary charges for services used in excising the cadaver kidney to the transplant hospital or organ procurement agency.
  • If the transplanting hospital's organ procurement team excises the cadaver kidney at another hospital, the cost of operating such a team is included in the transplanting hospital's kidney acquisition costs, along with the reasonable charges billed by the other hospital of its services.

Tissue Typing and Pre-transplant Evaluation

  • Tissue typing and pre-transplant evaluation can be reflected only through the kidney acquisition charge of the hospital where the transplant will take place.
  • Include the reasonable charges paid to the independent laboratory or other hospital which typed the potential transplant recipient, either before or after his entitlement.
  • Include the 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).

Services to Donors Prior to Excision

  • 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.

Overview of the Kidney Acquisition Charge
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.

Billing for Kidney Acquisition (Live Donor and Cadaver Donor): Transplant Hospital

  • Use type of bill (TOB) 11X.
  • Provide the standard kidney acquisition charge on revenue code 081X. These charges are not considered for the IPPS outlier calculation when a procedure code beginning with 556 is reported.
    • Revenue code 0811: living kidney donor acquisition
    • Revenue code 0812: cadaver kidney donor acquisition
  • For charges from the excising hospital, keep an itemized statement that identifies:
    • Services furnished
    • Charges
    • The person receiving the service (donor/recipient)
    • 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 reflects the average, all-inclusive cost associated with each type of kidney acquisition (including tissue typing and post-operative evaluation), not the cost associated with a specific kidney.
  • For interim bills: submit the standard acquisition charge on the billing form for the period during which the transplant took place. This charge is in addition to the hospital's charges for services rendered directly to the Medicare recipient. Interim payment is paid as a "pass through" item.
  • Special note for PPS hospitals: CGS deducts kidney acquisition charges for PPS hospitals for processing through Pricer. These costs (which are incurred by approved kidney transplant hospitals) are notincluded in the kidney transplant prospective payment. They are paid on a reasonable cost basis.

Bill Review Procedures
There is a Limited Coverage edit for procedure code 55.69 (kidney transplant). When procedure code 55.69 is billed, CGS checks the provider number to determine whether the provider is an approved transplant center and checks the effective approval date.

Billing for Donor Post-Kidney Transplant Complication Services
These charges are covered and separately billable only if they are directly attributable to the donation surgery.

  • Submit services for donor complications using the recipient’sHealth Insurance Claim (HIC) number
  • Submit HCPCS modifier Q3 (Live Kidney Donor and Related Services) on each covered line of the claim that contains a HCPCS or CPT code.
  • Institutional claims must also include:
  • Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients)
  • Patient Relationship Code 39 (Organ Donor)
  • If the kidney recipient is deceased, CGS will override edit 5211 for donor complication claims that include HCPCS modifier Q3.


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