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)
as
of August 1 of the current year. 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).
2.0 EXCLUSIONS
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.