Heart Transplants

90.2 - Heart Transplants (Rev.: 13757; Issued: 04-30-26; Effective: 04-01-26; Implementation: 04-06-26) Cardiac transplantation is covered under Medicare when performed in a facility which is approved by Medicare as meeting institutional coverage criteria. On April 6, 1987, CMS Ruling 87-1, "Criteria for Medicare Coverage of Heart Transplants" was published in the "Federal Register." For Medicare coverage purposes, heart transplants are medically reasonable and necessary when performed in facilities that meet these criteria. If a hospital wishes to bill Medicare for heart transplants, it must submit an application and documentation, showing its ongoing compliance with each criterion. If a contractor has any questions concerning the effective or approval dates of its hospitals, it should contact its RO. For a complete list of approved transplant centers, visit: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf A. - Effective Dates The effective date of coverage for heart transplants performed at facilities applying after July 6, 1987, is the date the facility receives approval as a heart transplant facility. Coverage is effective for discharges October 17, 1986 for facilities that would have qualified and that applied by July 6, 1987. All transplant hospitals will be recertified under the final rule, Federal Register / Vol. 72, No. 61 / Friday, March 30, 2007, / Rules and Regulations. The CMS informs each hospital of its effective date in an approval letter. B. - Drugs Medicare Part B covers immunosuppressive drugs following a covered transplant in an approved facility. C. - Noncovered Transplants Medicare will not cover transplants or re-transplants in facilities that have not been approved as meeting the facility criteria. If a beneficiary is admitted for and receives a heart transplant from a hospital that is not approved, physicians' services, and inpatient services associated with the transplantation procedure are not covered. If a beneficiary received a heart transplant from a hospital while it was not an approved facility and later requires services as a result of the noncovered transplant, the services are covered when they are reasonable and necessary in all other respects. D. - Charges for Heart Acquisition Services The excising hospital bills the OPO, who in turn bills the transplant (implant) hospital for applicable services. It should not submit a bill to its contractor. The transplant hospital must keep an itemized statement that identifies the services rendered, the charges, the person receiving the service (donor/recipient), and whether this person is a potential transplant donor or recipient. These charges are reflected in the transplant hospital's heart acquisition cost center and are used in determining its standard charge for acquiring a donor's heart. The standard charge is not a charge representing the acquisition cost of a specific heart; rather, it reflects the average cost associated with each type of heart acquisition. Also, it is an all inclusive charge for all services required in acquisition of a heart, i.e., tissue typing, post- operative evaluation, etc. Acquisition charges shall be billed on a 081X revenue code. Such charges are not considered for the IPPS outlier calculation when billed for a heart transplant. E. - Bill Review Procedures The shared system takes the following actions to process heart transplant bills. It may accomplish them manually or modify its MCE and Grouper interface programs to handle the processing. 1. MCE Interface The MCE creates a Limited Coverage edit for heart transplant procedure codes. Where these procedure codes are identified by MCE, the shared system checks the provider number to determine if the provider is an approved transplant center, and checks the effective approval date. The shared system shall also determine if the facility is certified for adults and/or pediatric transplants. If payment is appropriate (i.e., the center is approved, and the service is on or after the approval date) it overrides the limited coverage edit. 2. Handling Heart Transplant Billings From Nonapproved Hospitals Where a heart transplant and covered services are provided by a nonapproved hospital, the bill data processed through Grouper and Pricer must exclude transplant procedure codes and related charges.