Billing for Liver Transplant and Acquisition Services

90.4.2 - Billing for Liver Transplant and Acquisition Services (Rev.: 13757; Issued: 04-30-26; Effective: 04-01-26; Implementation: 04-06-26) The inpatient claim is completed in accordance with instructions in chapter 25 for the beneficiary who receives a covered liver transplant. Applicable standard liver acquisition charges are identified separately by revenue code 081X. Where interim bills are submitted, the standard acquisition charge appears on the billing form for the period during which the transplant took place. This charge is in addition to the hospital's charge for services furnished directly to the Medicare recipient. The contractor deducts liver acquisition charges for IPPS hospitals prior to processing through Pricer. Costs of liver acquisition incurred by approved liver transplant facilities are not included in the liver transplant prospective payment. They are paid on a reasonable cost basis. This item is a "pass-through" cost for which interim payments are made. (See the Provider Reimbursement Manual, Part 1, §2802 B.8.) The contractor includes liver acquisition charges under revenue code 081X in the HUIP record that it sends to CWF and the QIO. MCE Interface The MCE contains a limited coverage edit for liver transplant procedures using below ICD- 10-CM codes if ICD-10-CM is applicable. Nationally Covered Diagnosis Codes Diagnosis Code Description B16.0 Acute hepatitis B with delta-agent with hepatic coma B16.1 Acute hepatitis B with delta-agent without hepatic coma B16.2 Acute hepatitis B without delta-agent with hepatic coma B16.9 Acute hepatitis B without delta-agent and without hepatic coma B17.0 Acute delta-(super) infection of hepatitis B carrier B17.10 Acute hepatitis C without hepatic coma B17.11 Acute hepatitis C with hepatic coma B17.2 Acute hepatitis E B17.8 Other specified acute viral hepatitis B17.9 Acute viral hepatitis, unspecified B18.0 Chronic viral hepatitis B with delta-agent B18.1 Chronic viral hepatitis B without delta-agent B18.2 Chronic viral hepatitis C B18.8 Other chronic viral hepatitis B18.9 Chronic viral hepatitis, unspecified B19.0 Unspecified viral hepatitis with hepatic coma Diagnosis Code Description B16.0 Acute hepatitis B with delta-agent with hepatic coma B16.1 Acute hepatitis B with delta-agent without hepatic coma B16.2 Acute hepatitis B without delta-agent with hepatic coma B19.10 Unspecified viral hepatitis B without hepatic coma B19.11 Unspecified viral hepatitis B with hepatic coma B19.20 Unspecified viral hepatitis C without hepatic coma B19.21 Unspecified viral hepatitis C with hepatic coma B19.9 Unspecified viral hepatitis without hepatic coma C22.0 Liver cell carcinoma E70.1 Other hyperphenylalaninemias E70.20 Disorder of tyrosine metabolism, unspecified E70.21 Tyrosinemia E70.29 Other disorders of tyrosine metabolism E70.30 Albinism, unspecified E70.310 X-linked ocular albinism E70.311 Autosomal recessive ocular albinism E70.318 Other ocular albinism E70.319 Ocular albinism, unspecified E70.320 Tyrosinase negative oculocutaneous albinism E70.321 Tyrosinase positive oculocutaneous albinism E70.328 Other oculocutaneous albinism E70.329 Oculocutaneous albinism, unspecified E70.330 Chediak-Higashi syndrome E70.331 Hermansky-Pudlak syndrome E70.338 Other albinism with hematologic abnormality E70.339 Albinism with hematologic abnormality, unspecified E70.39 Other specified albinism E70.40 Disorders of histidine metabolism, unspecified E70.41 Histidinemia E70.49 Other disorders of histidine metabolism E70.5 Disorders of tryptophan metabolism E70.81 Aromatic L-amino acid decarboxylase deficien E70.89 Other disorders of aromatic amino-acid metabolism E70.9 Disorder of aromatic amino-acid metabolism, unspecified E71.0 Maple-syrup-urine disease E71.110 Isovaleric acidemia E71.111 3-methylglutaconic aciduria E71.118 Other branched-chain organic acidurias E71.120 Methylmalonic acidemia E71.121 Propionic acidemia E71.19 Other disorders of branched-chain amino-acid metabolism E71.2 Disorder of branched-chain amino-acid metabolism, unspecified E71.30 Disorder of fatty-acid metabolism, unspecified E71.310 Long chain/very long chain acyl CoA dehydrogenase deficiency E71.311 Medium chain acyl CoA dehydrogenase deficiency Diagnosis Code Description E71.312 Short chain acyl CoA dehydrogenase deficiency E71.313 Glutaric aciduria type II E71.314 Muscle carnitine palmitoyltransferase deficiency E71.318 Other disorders of fatty-acid oxidation E71.32 Disorders of ketone metabolism E71.39 Other disorders of fatty-acid metabolism E71.40 Disorder of carnitine metabolism, unspecified E71.41 Primary carnitine deficiency E71.42 Carnitine deficiency due to inborn errors of metabolism E71.43 Iatrogenic carnitine deficiency E71.440 Ruvalcaba-Myhre-Smith syndrome E71.448 Other secondary carnitine deficiency E71.50 Peroxisomal disorder, unspecified E71.510 Zellweger syndrome E71.511 Neonatal adrenoleukodystrophy E71.518 Other disorders of peroxisome biogenesis E71.520 Childhood cerebral X-linked adrenoleukodystrophy E71.521 Adolescent X-linked adrenoleukodystrophy E71.522 Adrenomyeloneuropathy E71.528 Other X-linked adrenoleukodystrophy E71.529 X-linked adrenoleukodystrophy, unspecified type E71.53 Other group 2 peroxisomal disorders E71.540 Rhizomelic chondrodysplasia punctata E71.541 Zellweger-like syndrome E71.542 Other group 3 peroxisomal disorders E71.548 Other peroxisomal disorders E72.00 Disorders of amino-acid transport, unspecified E72.01 Cystinuria E72.02 Hartnup's disease E72.03 Lowe's syndrome E72.04 Cystinosis E72.09 Other disorders of amino-acid transport E72.10 Disorders of sulfur-bearing amino-acid metabolism, unspecified E72.11 Homocystinuria E72.12 Methylenetetrahydrofolate reductase deficiency E72.19 Other disorders of sulfur-bearing amino-acid metabolism E72.20 Disorder of urea cycle metabolism, unspecified E72.21 Argininemia E72.22 Arginosuccinic aciduria E72.23 Citrullinemia E72.29 Other disorders of urea cycle metabolism E72.3 Disorders of lysine and hydroxylysine metabolism E72.4 Disorders of ornithine metabolism E72.50 Disorder of glycine metabolism, unspecified E72.51 Non-ketotic hyperglycinemia Diagnosis Code Description E72.52 Trimethylaminuria E72.53 Primary hyperoxaluria E72.59 Other disorders of glycine metabolism E72.81 Disorders of gamma aminobutyric acid E72.89 Other specified disorders of amino-acid metabolism E72.9 Disorder of amino-acid metabolism, unspecified E80.0 Hereditary erythropoietic porphyria E80.29 Other porphyria E83.00 Disorder of copper metabolism, unspecified E83.01 Wilson's disease E83.09 Other disorders of copper metabolism E83.110 Hereditary hemochromatosis E83.111 Hemochromatosis due to repeated red blood cell transfusions E83.118 Other hemochromatosis E83.119 Hemochromatosis, unspecified E85.0 Non-neuropathic heredofamilial amyloidosis E85.1 Neuropathic heredofamilial amyloidosis E85.2 Heredofamilial amyloidosis, unspecified E85.3 Secondary systemic amyloidosis E85.4 Organ-limited amyloidosis E85.89 Other amyloidosis E88.01 Alpha-1-antitrypsin deficiency E88.02 Plasminogen deficiency I82.0 Budd-Chiari syndrome K70.0 Alcoholic fatty liver K70.10 Alcoholic hepatitis without ascites K70.11 Alcoholic hepatitis with ascites K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K70.40 Alcoholic hepatic failure without coma K70.41 Alcoholic hepatic failure with coma K70.9 Alcoholic liver disease, unspecified K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 Toxic liver disease with acute hepatitis K71.3 Toxic liver disease with chronic persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K71.8 Toxic liver disease with other disorders of liver K72.00 Acute and subacute hepatic failure without coma Diagnosis Code Description K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K73.1 Chronic lobular hepatitis, not elsewhere classified K73.2 Chronic active hepatitis, not elsewhere classified K73.8 Other chronic hepatitis, not elsewhere classified K73.9 Chronic hepatitis, unspecified K74.01 Hepatic fibrosis, early fibrosis K74.02 Hepatic fibrosis, advanced fibrosis K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K74.3 Primary biliary cirrhosis K74.4 Secondary biliary cirrhosis K74.5 Biliary cirrhosis, unspecified K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 Abscess of liver K75.1 Phlebitis of portal vein K75.2 Nonspecific reactive hepatitis K75.3 Granulomatous hepatitis, not elsewhere classified K75.4 Autoimmune hepatitis K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K75.9 Inflammatory liver disease, unspecified K76.0 Fatty (change of) liver, not elsewhere classified K76.1 Chronic passive congestion of liver K76.2 Central hemorrhagic necrosis of liver K76.3 Infarction of liver K76.4 Peliosis hepatis K76.5 Hepatic veno-occlusive disease K76.6 Portal hypertension K76.7 Hepatorenal syndrome K76.81 Hepatopulmonary syndrome K76.89 Other specified diseases of liver K77 Liver disorders in diseases classified elsewhere K83.01 Primary sclerosing cholangitis K83.09 Other cholangitis K83.1 Obstruction of bile duct K83.5 Biliary cyst K83.8 Other specified diseases of biliary tract K83.9 Disease of biliary tract, unspecified K91.82 Postprocedural hepatic failure Q44.1 Other congenital malformations of gallbladder Diagnosis Code Description Q44.2 Atresia of bile ducts Q44.3 Congenital stenosis and stricture of bile ducts Q44.4 Choledochal cyst Q44.6 Cystic disease of liver T86.40 Unspecified complication of liver transplant T86.41 Liver transplant rejection T86.42 Liver transplant failure Local Discretion Covered Diagnosis Codes Diagnosis Code Description C24.0 Malignant neoplasm of extrahepatic bile duct C7B.02 Secondary carcinoid tumors of liver D37.6 Neoplasm of uncertain behavior of liver, gallbladder and bile ducts Nationally NON-Covered Diagnosis Codes Diagnosis Code Description C22.1 Intrahepatic bile duct carcinoma C22.3 Angiosarcoma of liver C22.7 Other specified carcinomas of liver C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct C7A.1 Malignant poorly differentiated neuroendocrine tumors C7A.8 Other malignant neuroendocrine tumors C7B.8 Other secondary neuroendocrine tumors D01.5 Carcinoma in situ of liver, gallbladder and bile ducts D18.00 Hemangioma unspecified site D18.01 Hemangioma of skin and subcutaneous tissue D18.02 Hemangioma of intracranial structures D18.03 Hemangioma of intra-abdominal structures D18.09 Hemangioma of other sites D3A.8 Other benign neuroendocrine tumors The MCE contains a limited coverage edit for liver transplant procedures using ICD- 10-PCS codes, if ICD-10-PCS code is applicable. 0FY00Z0- Transplantation of Liver, Allogeneic, Open Approach 0FY00Z1-Transplantation of Liver, Syngeneic, Open Approach Where a liver transplant procedure code is identified by the MCE, the shared system shall check the provider number and effective date to determine if the provider is an approved liver transplant facility at the time of the transplant. Contractors shall use claims data to determine that the coverage criteria specified in Publication 100-03, Section 260.1 have been met. If payment is appropriate (i.e., the facility is approved, the service is furnished on or after the approval date, and the beneficiary has a covered condition), the contractor sends the claim to Grouper and Pricer. If none of the diagnosis’s codes are for a covered condition, the contractor denies the claim. NOTE: Some noncovered conditions are included in the covered diagnostic codes. (The diagnostic codes are broader than the covered conditions. Do not pay for noncovered conditions. Grouper If the bill shows a discharge date before March 8, 1990, the liver transplant procedure is not covered. If the discharge date is March 8, 1990 or later, the contractor processes the bill through Grouper and Pricer. If the discharge date is after March 7, 1990, and before October 1, 1990, Grouper assigned CMS DRG 191 or 192. The contractor sent the bill to Pricer with review code 08. Pricer would then overlay CMS DRG 191 or 192 with CMS DRG 480 and the weights and thresholds for CMS DRG 480 to price the bill. If the discharge date is after September 30, 1990, Grouper assigns CMS DRG 480 and Pricer is able to price without using review code 08. If the discharge date is after September 30, 2007, Grouper assigns MS-DRG 005 or 006 (Liver transplant with MCC or Intestinal Transplant or Liver transplant without MCC, respectively) and Pricer is able to price without using review code 08. Liver Transplant Billing From Non-approved Hospitals Where a liver transplant and covered services are provided by a non-approved hospital, the bill data processed through Grouper and Pricer must exclude transplant procedure codes and related charges. When CMS approves a hospital to furnish liver transplant services, it informs the hospital of the effective date in the approval letter. The contractor will receive a copy of the letter.