Pancreas Transplants Kidney Transplants

90.5 - Pancreas Transplants Kidney Transplants (Rev.: 13757; Issued: 04-30-26; Effective: 04-01-26; Implementation: 04-06-26) A. - Background Effective July 1, 1999, Medicare covered pancreas transplantation when performed simultaneously with or following a kidney transplant if ICD-9 is applicable, ICD-9-CM procedure code 55.69. If ICD-10 is applicable, the following ICD-10-PCS codes will be used: 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0. 0TY10Z1, and 0TY10Z2. Pancreas transplantation is performed to induce an insulin independent, euglycemic state in diabetic patients. The procedure is generally limited to those patients with severe secondary complications of diabetes including kidney failure. However, pancreas transplantation is sometimes performed on patients with labile diabetes and hypoglycemic unawareness. Medicare has had a policy of not covering pancreas transplantation. The Office of Health Technology Assessment performed an assessment on pancreas-kidney transplantation in 1994. They found reasonable graft survival outcomes for patients receiving either simultaneous pancreas-kidney (SPK) transplantation or pancreas after kidney (PAK) transplantation. For a list of facilities approved to perform SPK or PAK, refer to the following Web site: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf B. - Billing for Pancreas Transplants There are no special provisions related to managed care participants. Managed care plans are required to provide all Medicare covered services. Medicare does not restrict which hospitals or physicians may perform pancreas transplantation. The transplant procedure and revenue code 0360 for the operating room are paid under these codes. Procedures must be reported using the current ICD procedure codes for pancreas and kidney transplants. Providers must place at least one of the following transplant procedure codes on the claim: If ICD-9 Is Applicable 52.80 Transplant of pancreas 52.82 Homotransplant of pancreas The Medicare Code Editor (MCE) has been updated to include 52.80 and 52.82 as limited coverage procedures. The shared system shall determine if the facility is approved for the transplant and certified for either pediatric or adult transplants and Return To Provider (RTP) as appropriate. Effective October 1, 2000, ICD-9-CM code 52.83 was moved in the MCE to non-covered. The contractor must override any deny edit on claims that came in with 52.82 prior to October 1, 2000 and adjust, as 52.82 is the correct code. If the discharge date is July 1, 1999, or later: the contractor processes the bill through Grouper and Pricer. If ICD-10 is applicable, the following procedure codes (ICD-10-PCS) are: • 0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach • 0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach Pancreas transplantation is reasonable and necessary for the following diagnosis codes. However, since this is not an all-inclusive list, the contractor is permitted to determine if any additional diagnosis codes will be covered for this procedure. If ICD-9-CM is applicable, Diabetes Diagnosis Codes and Descriptions ICD-9- CM Code Description 250.00 Diabetes mellitus without mention of complication, type II (non-insulin dependent) (NIDDM) (adult onset) or unspecified type, not stated as uncontrolled. 250.01 Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), not stated as uncontrolled. 250.02 Diabetes mellitus without mention of complication, type II (non-insulin dependent) (NIDDM) (adult onset) or unspecified type, uncontrolled. 250.03 Diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), uncontrolled. 250.1X Diabetes with ketoacidosis 250.2X Diabetes with hyperosmolarity 250.3X Diabetes with coma 250.4X Diabetes with renal manifestations 250.5X Diabetes with ophthalmic manifestations 250.6X Diabetes with neurological manifestations 250.7X Diabetes with peripheral circulatory disorders 250.8X Diabetes with other specified manifestations 250.9X Diabetes with unspecified complication NOTE: X=0-3 If ICD-10-CM is applicable, the diagnosis codes are: E10.10 - E10.9 Hypertensive Renal Diagnosis Codes and Descriptions if ICD-9-CM is applicable: ICD-9-CM Code Description 403.01 Malignant hypertensive renal disease, with renal failure 403.11 Benign hypertensive renal disease, with renal failure 403.91 Unspecified hypertensive renal disease, with renal failure 404.02 Malignant hypertensive heart and renal disease, with renal failure 404.03 Malignant hypertensive heart and renal disease, with congestive heart failure or renal failure 404.12 Benign hypertensive heart and renal disease, with renal failure 404.13 Benign hypertensive heart and renal disease, with congestive heart failure or renal failure 404.92 Unspecified hypertensive heart and renal disease, with renal failure ICD-9-CM Code Description 404.93 Unspecified hypertensive heart and renal disease, with congestive heart failure or renal failure 585.1 - 585.6, 585.9 Chronic Renal Failure Code If ICD-10-CM is applicable, diagnosis codes and descriptions are: ICD-10-CM code Description I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified NOTE: If a patient had a kidney transplant that was successful, the patient no longer has chronic kidney failure, therefore it would be inappropriate for the provider to bill ICD-9-CM codes 585.1 - 585.6, 585.9 or, if ICD-10-CM is applicable, the diagnosis codes N18.1 - N18.9 on such a patient. In these cases one of the following codes should be present on the claim or in the beneficiary's history. The provider uses the following ICD-9-CM status codes only when a kidney transplant was performed before the pancreas transplant and ICD-9 is applicable: ICD-9- CM code Description V42.0 Organ or tissue replaced by transplant kidney V43.89 Organ tissue replaced by other means, kidney or pancreas If ICD-10-CM is applicable, the following ICD-10-CM status codes will be used: ICD-10- CM code Description Z48.22 Encounter for aftercare following kidney transplant Z94.0 Kidney transplant status NOTE: If a kidney and pancreas transplants are performed simultaneously, the claim should contain a diabetes diagnosis code and a renal failure code or one of the hypertensive renal failure diagnosis codes. The claim should also contain two transplant procedure codes. If the claim is for a pancreas transplant only, the claim should contain a diabetes diagnosis code and a status code to indicate a previous kidney transplant. If the status code is not on the claim for the pancreas transplant, the contractor will search the beneficiary's claim history for a status code indicating a prior kidney transplant. C. – Drugs If the pancreas transplant occurs after the kidney transplant, immunosuppressive therapy will begin with the date of discharge from the inpatient stay for the pancreas transplant. D. - Charges for Pancreas Acquisition Services A separate organ acquisition cost center has been established for pancreas transplantation. The Medicare cost report will include a separate line to account for pancreas transplantation costs. The 42 CFR 412.2(e)(4) was changed to include pancreas in the list of organ acquisition costs that are paid on a reasonable cost basis. Acquisition costs for pancreas transplantation as well as kidney transplants will occur in Revenue Center 081X. The contractor overrides any claims that suspend due to repetition of revenue code 081X on the same claim if the patient had a simultaneous kidney/pancreas transplant. It pays for acquisition costs for both kidney and pancreas organs if transplants are performed simultaneously. It will not pay for more than two organ acquisitions on the same claim. In addition, the contractor remove acquisition charges prior to sending the claims to Pricer so such charges are not included in the outlier calculation.