CSHCN 2009 > Physician > Benefits, Limitations, and Authorization Requirements

29.2.38 Transplants

29.2.38.1 Renal (Kidney) Transplant

Renal transplants are a benefit for CSHCN Services Program clients with chronic renal failure when the projected costs of the transplant and follow-up care are less than the cost of continuing dialysis treatments.

Clients who have not previously applied for Medicare and Kidney Health Care coverage and are anticipating the need for a renal transplant must apply for Medicare and Kidney Health Care coverage.

Renal transplants may only be considered for reimbursement when performed in a CSHCN Services Program-approved transplant center by a CSHCN Services Program-approved renal transplant surgeon. Renal transplants for clients who are younger than 15 years of age may be reimbursed only at CSHCN Services Program-approved pediatric renal transplant centers.

Refer to: Section 2.1.7, "Transplant Specialty Centers," on page 2-7.

Renal transplants must be prior authorized, and only an initial and one subsequent renal transplant may be reimbursed for a client as a lifetime benefit.

Documentation supporting the prior authorization request must include the following:

•A recent and complete history and physical

•A statement of the client's status including why a transplant is being recommended at this time

•Information indicating the cost effectiveness of the transplant versus continued dialysis

Refer to: Section 4.3, "Prior Authorizations" for detailed information about prior authorization requirements.

Appendix B, "CSHCN Services Program Prior Authorization Request for Bone Marrow, Stem Cell, or Renal Transplant," on page B-16.

Nationally, hospital stays for renal transplants in a hospital are 5 to 10 days followed by outpatient follow-up; therefore, no additional hospital days beyond the 60 per year allowed by the CSHCN Services Program may be authorized without an appeal documenting medical necessity.

If the transplant is not prior authorized, services directly related to the transplant within 3 days preoperative and during the 6 weeks postoperative period are denied for the surgeon, assistant surgeon, or facility. The anesthesiologist may be reimbursed.

The following procedure codes must be used to bill for physician services related to the renal transplant:

Procedure codes 50323, 50325, 50327, 50328, and 50329 are payable under the recipient. Procedure codes 60540 and 60545 will deny when billed on the same day by the same provider as 50323.

Procedure code 93975 or 93976 is denied if billed with the same date of service, by the same provider as procedure code 76776.

The following procedure codes will deny when billed on the same day by the same provider as procedure code 50300, 50320, 50340, 50365, or 50370:

Procedure code 50370 will deny when billed on the same day by the same provider as procedure code 50340.

The following procedure codes will deny when billed on the same day by the same provider as procedure code 50360:

Procedure code 50780 will deny when billed on the same day by the same provider as procedure code 50365 or 50380.

The following procedure codes will deny when billed on the same day by the same provider as procedure code 50547:

Procedure code 50650 will deny when billed on the same day by the same provider as procedure code 50320, 50340, or 50365.

Physicians may be reimbursed at the lower of the billed amount or the amount allowed by Texas Medicaid.

Reimbursement for renal transplants includes the cost of the transplant services and one of the following:

•The cost of procuring of a cadaveric organ and services associated procurement from an organ procurement organization (OPO) designated by the Secretary of Health and Human Services. Documentation validating the organ's source must accompany the claim.

•Donor costs for living donors. Donor costs must be included on the client's inpatient hospital claim and may only be reimbursed if another source of payment is not available. Donor costs for CSHCN Services Program clients who also have Medicaid will not be reimbursed.

A maximum amount of $200,000 per client may be reimbursed for a transplant hospitalization. All hospital charges for patient care (inpatient hospital only) during the time of the hospital stay are applied to the $200,000 limit. Donor costs are included in this $200,000 limit.

Renal transplant recipients are eligible for follow-up care (outside the $200,000 limit) immediately following hospital discharge.