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.