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 reportingCMS’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 costsToyon 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.
Below 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 Scott Besler at (925) 685-9312 or scott.besler@toyonassociates.com if you have any questions.