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Category: Organ Acquisition

Transplant/Organ Acquisition Reimbursement Update – December 4, 2020

 

– CMS issued final regulations for allogeneic stem cell acquisition requiring new processes for Medicare billing and cost reporting

– CMS’s updates and clarifying instructions to the Medicare cost report (2552-10), may have a significant impact to your hospital’s reimbursement for organ acquisition costs

 

Toyon Associates is pleased to provide this update on Transplant/Organ Acquisition Reimbursement.

1.  Medicare’s payment changes for Allogeneic Stem Cell Acquisition

In consideration of the comments received, effective for cost reports beginning on/after October 1, 2020, CMS finalized the regulations in the FFY 2021 IPPS Final Rule (page 58836) for the payment of allogeneic stem cell acquisition costs.

This change follows Section 108 of the Further Consolidated Appropriations Act of 2020 (Pub. L. 116-94) passed on 12/20/2019. Previously, IPPS payments for acquisition services for allogeneic stem cell transplants were included in MS–DRG 14 when the transplant occurs in the inpatient setting.

Highlights from the final rule:

  • Removes the requirement to formulate a Standard Acquisition Charge for all acquisition services provided in the hospital. However, hospitals will continue to establish charges with revenue code 815 for the direct/indirect costs assigned to line 77 of the Medicare cost report used to calculate a cost-to-charge ratio
  • For Medicare recipients only, hold actual donor search and hematopoietic stem cell acquisition charges performed in the hospital and include on the Medicare recipient’s transplant claim under revenue code 815 with other charges
  • A new Worksheet D-6, Part I of the Medicare cost report will be used to report only the Medicare (Part A and B) routine and ancillary acquisition charges to determine Medicare cost
  • Unlike solid organ acquisition, Medicare’s payment will be based on actual costs through Worksheet D-6 and not based on the ratio of Medicare to total (all payers) allogeneic stem cell transplants

Toyon’s Take on Payment Changes for Allogeneic Stem Cell Acquisition Costs

CMS’s changes will require an adjustment to the Revenue Cycle in holding donor search and hematopoietic stem cell acquisition charges performed in the hospital.  The acquisition charges added to the transplant recipient’s claim form will need to be in sufficient detail (e.g., by revenue code and department) to appropriately assign the charges to the new Worksheet D-6, Part I. Medicare utilization should be minimal for allogeneic bone marrow transplants.

Here are steps to prepare for the change in payment methodology:

  • Review/update the acquisition charge (revenue code 815) to determine if separate rates are needed for the type of stem cell transplant (i.e., related, unrelated, cord blood, etc.) to account for significant variation among the different types of donor search and stem cell acquisition services
  • Review internal Revenue Cycle processes for holding living donor hospital services associated with a Medicare recipient to capture the routine and ancillary charges for the Medicare cost report and adding to the transplant recipient’s claim form for the transplant
  • Review processes for capturing stem cell acquisition related expenses to include staffing, space, etc. for inclusion on line 77 of Worksheet A of the Medicare cost report (Toyon recommends a separate G/L department to capture the revenue and expenses for allogeneic stem cell acquisition)
  • Update Medicare cost report preparation process to exclude PS&R revenue code 815 charges from Worksheet D-3 (IPPS) and D Part V (OPPS)

2. Medicare cost report clarifying instructions and updated forms for organ acquisition

CMS issued a Notice (FR 85 71653) on November 10, 2020, to update the hospital Medicare cost report (CMS Form 2552-10) to address several changes in reporting. In addition, CMS added clarifying instructions to certain schedules with various effective dates.

Highlights of the significant changes:

  • Clarified to count as one organ for those procured en bloc (two organs procured as one unit) when transplanted into the same recipient
  • Clarified to exclude from total usable organs those organs excised with the intent to transplant but subsequently used for research. These are reported as unusable/discarded organs and only applicable to hospital-based OPOs as CTCs do not use organs for research.
  • Clarified to exclude organs excised from a deceased donor when an independent OPO transports the donor from the hospital to the independent OPO for organ recovery
  • Added line 63.01 to Worksheet D-4, Part III to report kidneys transplanted into Medicare Advantage beneficiaries (effective for transplants on or after January 1, 2021)
  • Added line 66.01 to Worksheet D-4, Part III to segregate revenue for organs sold for Medicare Secondary Payer (MSP) transplants (effective for periods on or after October 1, 2020)
  • Restated the proration of the primary payer offset amount for MSP transplants to be based on the charges submitted to the primary payer. Language in PRM1 3104 contradicts where the proration is based on the ratio of the Medicare DRG and organ acquisition payment.
  • Added four subscripts for line 75 (total organs transplanted) to Worksheet D-4, Part IV to separate organs transplanted between Medicare primary, Medicare Advantage (kidney only), Medicare Secondary Payer, and All Other

Toyon’s Take on the Update to Medicare Cost Report Forms and Clarifying Instructions

The updated forms and instructions remove the ambiguity in current instructions and guidelines. These include counting en bloc organs as one unit, basing the MSP revenue offset on submitted charges rather than the Medicare DRG, and counting organs intended for transplant but ultimately used for research for hospital-based OPOs. However, the clarification to exclude organs sent to the independent OPOs donor recovery center may be a hindrance for future collaboration between OPOs and CTCs since these cannot be counted as Medicare organs for the hospital’s Medicare cost report.

Here are steps to prepare for the changes in the forms and instructions:

  • Adjust usable organs to count en-bloc organs (kidneys and lungs) as one organ if transplanted into the same patient and adjust the allocation of deceased donor procurement days, charges, and revenue received for the en bloc organs
  • Adjust the proration for the MSP revenue offset, which is to be based on submitted charges
  • Exclude the deceased donor charges, organ counts, and any OPO payment for deceased donors transported to the independent OPO’s donor recovery center from Worksheet D-4

Toyon is committed to apprising our clients with important reimbursement updates impacting transplant and organ acquisition reimbursement.  Please contact Robert Howey at 888.514.9312 ext. 3147 or robert.howey@toyonassociates.com if you have any questions. 

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Transplant/Organ Acquisition Reimbursement Industry Update

For Hospitals Performing Bone Marrow and Kidney Transplants

 

– New policies will impact future Medicare cost reporting and reimbursement.

– Medicare’s payment changes on Allogeneic Stem Cell Acquisition can improve revenue and requires precise documentation (effective for cost reporting periods beginning on or after October 1, 2020).

– With restructured billing processes, kidney transplant centers will be reimbursed for acquisition costs for Medicare Advantage patients through the Medicare cost report (effective January 1, 2021). 

 

Toyon Associates is pleased to provide this update on Transplant/Organ Acquisition Reimbursement.

1. Medicare’s payment changes on Allogeneic Stem Cell Acquisition

Medicare reimbursement of allogeneic acquisition costs will be based on a reasonable-cost methodology effective for cost reporting periods beginning on or after October 1, 2020. Precise documentation of allogeneic stem cell acquisition costs is imperative as CMS will apply the ratio of Medicare to total (all payers) allogeneic stem cell transplants as the basis of this reimbursement method. This is a similar method CMS uses for reimbursing the acquisition costs of solid organs.

This change follows Section 108 of the Further Consolidated Appropriations Act of 2020 (Pub. L. 116-94) passed on 12/20/2019. Currently, IPPS payments for acquisition services associated with allogeneic hematopoietic stem cell transplants are included in MS–DRG 14 when the transplant occurs in the inpatient setting.

 

CMS provides more detail on the implementation in the FFY 2021 IPPS Proposed Rule (page 32762) to include the following:

  • Definition of Allogeneic Hematopoietic Stem Cell Transplant
  • Future development of a cost report worksheet, (i.e., similar to Worksheet D-4) for solid organs, to capture costs from Worksheet A, line 77 as well as report routine and ancillary charges to compute related costs.

Medicare reimbursement methodology using allogeneic acquisition costs will be based on the ratio of Medicare to total (all payers) allogeneic stem cell transplants.

CMS also updates the definition of allogeneic stem cell acquisition costs to include:

  • National donor registry fees (e.g., NMDP)
  • Tissue typing of donor and recipient
  • Donor evaluation
  • Physician pre-admission/pre-procedure donor evaluation services
  • Costs associated with the collection procedure, such as general routine and special care services, procedure/operating room and other ancillary services, and apheresis services, post-operative/post-procedure evaluation of donor
  • Preparation and processing of stem cells derived from bone marrow, peripheral blood stem cells, or cord blood (excluding embryonic stem cells)

Toyon’s Take on Reimbursement for Allogeneic Stem Cell Acquisition Costs

This is positive news for Medicare reimbursement of allogeneic bone marrow transplants as the MS-DRG payment was in most cases insufficient to cover the acquisition costs alone. The shift to the reasonable cost methodology aligns processes to those for solid organ although Medicare utilization should be low for bone marrow transplants.

Listed below are recommendations to prepare for the change in methodology:

  • Review historical volume for MS-DRG 14 (Allogeneic Bone Marrow Transplant) to assess the financial impact (Note that the decrease of the MS-DRG relative weight will also lower reimbursement for IME, DSH, and outliers)
  • Review/update the standard acquisition charge (revenue code 815) to confirm that it is inclusive of the average acquisition costs for this type of transplant
  • Review internal processes for flagging living donor hospital services to be able to capture all payer charges for the Medicare cost report
  • Review internal process to confirm living donor services are not billed to Medicare fee-for-service as these charges will be reimbursed through the Medicare cost report
  • Review processes for capturing stem cell acquisition related expenses include staffing, space, etc. for inclusion on line 77 of Worksheet A of the Medicare cost report (Toyon recommends having a separate G/L department to capture the revenue and expenses for allogeneic stem cell acquisition)

2.  Kidney Acquisition Costs for Medicare Advantage Transplants

Effective January 1, 2021, kidney acquisition costs for MA enrollees will be covered under the original Medicare program and reimbursed under the reasonable cost methodology in the Medicare cost report (i.e., the MA kidney transplant will be counted as a Medicare usable organ on Worksheet D-4, Part III, line 63). 

This change is per CMS’s Final Rule (FR 85 33796) dated June 2, 2020, to implement sections of the 21st Century Cures Act (Pub. L. 114-255), which expanded enrollment options for individuals with end stage renal disease (ESRD). The new enrollment option will impact reimbursement for kidney acquisition costs from MA plans and original Medicare. Currently, individuals with ESRD are unable to enroll in Medicare Advantage (MA) plans except in limited circumstances.

Toyon’s Take on Medicare Advantage Kidney Transplants

This should be positive news for kidney transplant centers. Many MA plans already utilize the Medicare reimbursement methodology through inclusion of the hospital’s most recently filed cost report worksheets. For those kidney programs where MA plans had low case rates or carve outs for kidney acquisition, this will be beneficial to recoup the actual acquisition costs for kidney transplant.

Listed below are recommendations to prepare for the change in methodology (effective January 1, 2021):

  • Modify billing processes to no longer submit kidney acquisition related claims (e.g., pre-transplant services) to MA plans if including on the Medicare cost report
  • Continue to submit hospital inpatient claims to the MA plan for the transplant procedure and exclude the kidney standard acquisition charge (revenue code 081x) from the claim form. (Note: For multi-organ transplants, continue to include the extra renal standard acquisition charge)
  • Continue to submit “no pay” bills to the Medicare Administrative Contractors (MACs) to accumulate the inpatient days and simulated payments captured in PS&R report type 118.
  • Update internal processes to include MA kidney transplants in the Medicare count of the Medicare cost report effective for kidney transplants occurring on or after January 1, 2021

Toyon is committed to apprising our clients with important reimbursement updates impacting transplant and organ acquisition reimbursement. Please contact Robert Howey at 888.514.9312 ext. 3147 or robert.howey@toyonassociates.com if you have any questions about these updates. 

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