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TAG does a complete in-depth analysis and assessment to determine the cost for the outpatient transplant clinic, pre-transplant costs, and all other costs relating to organ acquisition. This assessment is critical to ensure that all services are properly reimbursed by the appropriate payer (e.g. Medicare, Medicaid, Tricare, etc.). The following is an overview of services and costs that are typically associated with these transplant/organ acquisition services.

I)    Outpatient Transplant Clinic

• Collection of all appropriate patient information
• Approval of health insurance coverage
• Consultations with the primary physician(s), transplant physician(s), and other hospital personnel
• Review of all prior medical records
• Laboratory studies (blood and urine tests) and radiological studies (X-ray, EKG, CT or MRI)
• Additional tests, depending on the patient's condition and medical history

II)    Pre-Transplant Costs

Pre-Transplant Evaluation:

Typical diagnostics routinely performed during the pre-transplant evaluation period for all transplant candidates include the following:

• Physical exam (with complete medical and surgical history)
• Blood tests (e.g. blood typing, HLA)
• Routine laboratory
• Other basic diagnostics (Skin testing for tuberculosis, chest x-ray, electrocardiogram, and peripheral vascular studies)
• Cardiac evaluation
• Dental consultation (to rule out infectious agents)
• Standard cancer screening
• Social services consultation with possible psychiatric consultation

Completion of the initial evaluation period may take a few days to months. Following the evaluation period, the patient’s information is collected and reviewed by the transplant review board to determine if the patient is a candidate for transplant.

Living Donor:

Options for living donations are presented to most kidney and liver pre-transplant patients and may also be offered to prospective lung, intestine, and pancreas transplant candidates at select programs.  The donor evaluation will generally include the following studies:


• Laboratory tests
• Other basic diagnostics (skin testing for tuberculosis, chest x-ray and electrocardiogram, CT scan or arteriogram to evaluate renal arteries/veins, anatomy of kidney donor)
• Cardiology evaluation

Organ Procurement:

The costs associated with cadaveric organ acquisition and procurement varies by the organ procurement organization with established standard acquisition costs (SAC). Medicare Administrator Contractors approve SAC fees for each state. For this service, the typical charges include the following:


• Screening for infectious diseases
• Laboratory services
• Chest x-rays
• Operating room services
• Surgical fees
• Transportation services

III)    Financial Review of the Organ Acquisition/Transplant Center:

A.    Immunosuppressive Drugs

Immunosuppressive drugs that act to suppress the body’s normal immune reactions are a critical medical therapy for persons who have received organ transplants. Most transplant patients must continue immunosuppressive drug therapy throughout their lives to prevent organ rejection.

Medicare transplant recipients have initial access to outpatient immunosuppressive therapy.  For ESRD patients only, Medicare’s coverage of this therapy is limited to three years, starting with the patient’s discharge from the hospital after a Medicare-covered transplant procedure.

Oral immunosuppressive drugs (and other non-oral forms) are specially covered under Medicare Part B.  Immunosuppressive drugs covered by Medicare Part B are listed here.

Please note Medicare coverage for immunosuppressant drugs in the following circumstances:

• Immunosuppressant drugs remain a Medicare Part B benefit for recipients who have a Medicare-covered transplant.
• Medicare Part B and Part D are separate programs that do not work together to share costs for any Medicare-covered drugs. Therefore, Medicare Part D will not pick up some or all of the 20% co-insurance for immunosuppressant drugs.
• Fee-for-service Medicaid of State Qualified Medicare Beneficiary programs remains responsible for Medicare Part B co-insurance for Medicare/Medicaid eligible patients.
• At this time, Medicare will cover 80% of approved immunosuppressant medications.
• If the patient receives Social Security Disability Income or is over the age of 65, 80% Medicare coverage for these specific medications will be for the life of the patient.
• If the patient receives Medicare benefits primarily due to end stage renal disease, the 80% Medicare coverage for these medications will be expected to terminate three years after the transplant.

Medicare covers prescription drugs used in immunosuppressive therapy when:

• The drugs are prescribed following a kidney, heart, liver, bone marrow/stem cell, lung, heart/lung transplant, whole organ pancreas transplant performed at the same time as or following a kidney transplant because of diabetic nephropathy or intestinal transplant;
• The transplant met Medicare coverage criteria in effect at the time;
• The patient was enrolled in Medicare Part A at the time of the transplant and is enrolled in Medicare Part B at the time that the drugs are dispensed;
• The drugs are used to prevent or treat rejection of an organ transplant in the particular patient;
• The drugs are provided on or after the date of discharge from the hospital following a covered organ transplant.

Immunosuppression Types:

Post-transplant immunosuppression almost always includes a combination of drugs and approaches based on a patient’s individual situation, organ transplanted and current developments in the field.  Depending on these factors, approaches could include:

• Induction Immunosuppression: This approach includes all medications given immediately after transplantation in intensified doses for the purpose of preventing acute rejection. Although the drugs may be continued after discharge for the first 30 days after transplant, they are not used long-term for immunosuppressive maintenance.  Associated medications can include Methylprednisolone, Atgam, Thymoglobulin, OKT3, Basiliximab or Daclizumab.
• Maintenance Immunosuppression: Maintenance includes all immunosuppressive medications given before, during or after the transplant with the intention of long-term maintenance. An example of the medications include: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine or Rapamycin. In addition, maintenance immunosuppression does not include any immunosuppressive medications given to treat rejection episodes or for induction.
• Anti-Rejection Immunosuppression: This approach includes all immunosuppressive medications given for the purpose of treating an acute rejection episode during the initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection. Associated medications can include Methylprednisolone, Atgam, OKT3, Thymoglobulin, Basiliximab or Daclizumab.

 

B.    Post-Transplant Complication Services

The donor of an organ for Medicare transplant beneficiary is covered for an unlimited number of days of care in connection with the organ removal operation.  Days of inpatient hospital care used by the donor in connection with the organ removal operation shall not be charged against either party’s utilization record.  However, the program’s assumption of liability is limited to those donor expenses that are incurred directly in connection with the organ donation.

Donor Follow-Up:

• Expenses incurred by the transplant center for routine donor follow-up care are included in the transplant center's organ acquisition cost center.
• Follow-up services performed by the operating physician 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.
• Follow-up services billed by a physician other than the operating physician for up to three months should be billed under the recipient's health insurance claim number.

Donor Complications:

• Expenses incurred for complications that arise with respect to the donor are covered only if they are directly attributable to the donation surgery. Complications that arise after the date of the donor's discharge will be billed under the recipient's health insurance claim number.This is true for both the facility cost and physician services. Billing for donor complications will be reviewed.
• In all of these situations, the donor is not responsible for co-insurance or deductible.

C.    Organ Transplant Services Covered by Medicare

Medicare covers the following transplant services and pays part of their cost:

Service or Supply	Medicare Part A	Medicare Part B
Inpatient services in an approved hospital	X
Organ registry fee	X
Laboratory and other tests needed to evaluate the medical condition of potential organ donors	X
The costs of finding the proper organ for transplant surgery (if there is no organ donor)	X
The full cost of care for the organ donor (including care before surgery, the actual surgery, and care after surgery)	X
Any additional inpatient hospital care for the donor in case of problems due to the surgery	X
Doctors’ services for organ transplant surgery (including care before surgery, the actual surgery, and care after surgery)		X
Doctors’ services for the organ donor during their hospital stay		X
Immunosuppressive drugs (for a limited time after the patient leaves the hospital following a transplant)		X
Blood (whole or units of packed red blood cells, blood components, and the cost of processing and giving blood)	X	X

 

D.    Billing Donor and Recipient Pre-Transplant Services

The transplant hospital prepares an itemized statement of the services rendered for submittal to its cost accounting department.  Regular Medicare patient billing forms are not necessary for this purpose, since no bills are submitted to the Medicare Administrative Contractor (MAC) at this point. 

The itemized statement should contain information that identifies the person receiving the service (donor/recipient), the health care insurance number, the services rendered and the charge for the services, 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.

Billing for Cadaveric Donor Services:

In general, 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 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 determinations.

Billing for Physicians’ Services After Transplantation:

All physicians’ services rendered to the living donor and to the transplant recipient are billed to the Medicare program in the same manner as all Medicare Part B services.  All donor physicians’ services must be billed to the account of the recipient (i.e., the recipient’s Medicare number).

Billing for Organ Transplant and Acquisition Services:

Applicable standard kidney acquisition charges are identified by specific uniform billing revenue codes (e.g. code 0811, for Living Donor Kidney Acquisition and code 0812, for Cadaver Donor Kidney Acquisition).  Where interim bills are submitted, the standard acquisition charge appears 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.

The Standard Organ 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 organs:


• The standard charge for acquiring a live donor (e.g. kidney, liver);
• The standard charge for acquiring a cadaver organ.

The standard charge is not a charge representing the acquisition cost of a specific organ; rather, it is a charge that reflects the average cost associated with each type of organ acquisition.

Acquisition services are billed from the excising hospital to the transplant hospital.  A patient bill is not submitted from the excising hospital to the Medicare Administration Contractor (MAC).  The transplant hospital keeps an itemized billing statement that identifies the services given, the charges, the person receiving the services (donor/recipient), and whether this is a potential transplant donor or recipient.  These charges are reflected in the transplant hospital’s organ acquisition cost center and are used in determining the hospital’s standard charge for acquiring a live donor’s organ or a cadaver’s organ.

E.    Payer/Insurance for Organ Transplants

The most common funding sources for transplant services are:

• Private insurance
• Extending insurance coverage through COBRA
• Medicare (for more information, click here)
• Medicaid (for more information, click here)
• TRICARE (for more information, click here)
• Veterans Administration (VA) (for more information, click here)
• Managed Care/HMOs (Medicare Advantage, Commercial Health Insurers, etc.) (for more information, click here)
• Other sources of insurance/funding