1.0 POLICY
The policy provides an equitable means of payment
for reasonable organ acquisition services/costs required to support
quality transplant programs. Since TRICARE does not have any reporting mechanisms
in place comparable to Medicare’s costs reports (Centers for Medicare
and Medicaid Services (CMS) Forms 2552 and 216) that can be utilized
in the development of TRICARE specific organ acquisition costs,
Medicare Standard Acquisition Charges (SACs) shall be used for reimbursement
of the reasonable and necessary costs associated with solid organ
acquisition. The complexity of the required reporting systems would
be neither administratively feasible nor cost effective for establishment
of TRICARE specific organ acquisition costs. The use of Medicare
SACs would also be in accordance with the statutory provisions under
10 United States Code (USC) 1079(h) and 10 USC 1079(i)(2) that payments
for institutional and individual providers be determined to the
extent practicable in accordance with the same reimbursement rules
as apply to payments to providers of services of the same type under
Title XVIII of the Social Security Act.
1.1 Organ Acquisition Costs
1.1.1 Certified Transplant Centers
(CTCs) are paid a prospective payment rate based on the reasonable
and necessary costs associated with acquiring the organ (i.e., organ
acquisition costs). The organ acquisition costs incurred by the
CTC or Organ Procurement Organization (OPO), either hospital-based
(HOPO) or independent (IOPO) are included on the appropriate organ
acquisition cost center on its Medicare Cost Report (MCR) - Form
CMS 2552 for CTCs/HOPOs and Form CMS 216 for IOPOs.
1.1.2 CTCs must develop two Medicare
SACs based on costs expected to be reasonably and necessarily incurred
in the acquisition of an organ:
• The SAC for acquiring
a living donor organ; and
• The SAC for acquiring
a cadaveric donor organ.
1.1.3 The SAC does not represent
the acquisition cost of an individual organ. Instead, it is a charge
which reflects an average of the total actual costs associated with
procuring either a cadaveric donor organ or a living donor organ,
by type of organ. When a CTC/HOPO provides an organ to another CTC
or OPO, the CTC/HOPO that provides the organ must bill its SAC.
When a CTC bills TRICARE for the transplant, it must use its Medicare
SAC for the procured organ. The costs of procuring an organ cannot be
billed directly to TRICARE because the procurement of an organ is
not a covered service when performed independent of a TRICARE covered
transplant.
1.2 Living
Donor Standard Acquisition Charge
The living
donor SAC is an average charge developed for each type of organ
by estimating the reasonable and necessary costs expected to be
incurred for services furnished to living donors and preadmission
services furnished to recipients of living donor organs during the
hospital’s cost reporting period.
1.3 Cadaveric Donor Standard Acquisition
Charges
The cadaveric donor SAC is an average
charge developed for each type of organ by estimating the reasonable
and necessary costs expected to be incurred in procuring cadaveric
organs, combined with the expected costs of acquiring cadaveric
organs from other sources.
1.4 Requirements For Organ Acquisition
Reimbursement
CTCs are to be paid costs for
organ acquisition reimbursement under TRICARE, under one of two
methods:
1.4.1 Annually, by August 1st, each Managed Care
Support Contractor (MCSC) shall survey all hospitals that had an
organ acquisition cost within the past fiscal year, asking them
to list their current Medicare SACs (living and cadaver organs).
Details for reporting the Medicare SACs are contained in DD Form
1423, Contract Data Requirements List (CDRL), located in Section
J of the applicable contract. TRICARE will reimburse CTC’s their
Medicare SAC and if not obtainable, reimbursement will follow
paragraph 1.4.2.
1.4.2 If the
Medicare SACs cannot be obtained from the CTC, the hospital’s overall
operating Cost-To-Charge Ratio (CCR) should be used to reduce charges
in the Organ Acquisition Revenue Center codes (081X) to costs. This
is the default payment method if SAC information is not transmitted
to TRICARE. Such charges, costs and reimbursement are to be reported
separately from the inpatient claim on a TRICARE Encounter Data
Non-Institutional (TED-N) using Healthcare Common Procedure Coding
System (HCPCS) code S2152, with the appropriate Pricing Rate Code
(PRC).
The actual organ transplant that is paid a
prospective payment system rate based on a Diagnosis Related Groups
(DRGs).
2.1 Services
Provided To Recipients
2.1.1 The services of a surgeon who performs an organ
transplant and assumes responsibility for:
• The patient’s postoperative
surgical care for 60 days; or
• Both the postoperative
surgical care and the related course of immunosuppressant therapy
for 60 days.
2.1.2 Physician backbench standard
preparation work, as defined by the Current Procedure Terminology
(CPT) code, performed on organs transplanted into a recipient.
2.1.3 Laboratory tests performed
for the recipient after the recipient leaves the CTC following the transplant.
2.2 Services Provided To Living
Donors
2.2.1 Physician
services to a living donor provided in connection with an organ
donation to a TRICARE beneficiary. These services include the donor’s
organ excision and inpatient stay.
2.2.2 Follow-up services performed
by the operating physician that are included in the 90-day global
payment for the surgery.
2.2.3 Follow-up services billed by a physician other
than the operating physician for up to three months following donation
surgery.