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 The contractor shall, annually
by August 1, 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. For reporting requirements, see 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 calendar days; or
• Both the postoperative surgical
care and the related course of immunosuppressant therapy for 60
calendar 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.