Claim Payment Policy

---

Title:

Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)

Policy #:

06.03.05d

---

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified. In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits. For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's coverage and reimbursement position for the collection, storage, and subsequent transfusion of autologous blood. For information regarding autologous platelet-derived growth factors, refer to the medical policy addressing this topic. For information regarding bone marrow and hematopoietic stem cell transplantation, refer to the medical policy addressing this topic.

Description

Autologous blood collection and storage allows an individual to have has his/her own blood drawn and stored for personal use, such as self-donation in advance of a planned surgical procedure (preoperative). Autologous blood transfusion is the precollection and subsequent infusion of an individual's own blood. Perioperative blood salvage is the collection and reinfusion of blood lost during and immediately after surgery.

Policy

Autologous blood services (including collection, storage, transfusion, and perioperative salvage) are covered and eligible for reimbursement consideration by most Company products and groups when provided in conjunction with a planned episode of care that requires transfusion including, but not limited to, surgical procedures. Benefits are provided for the storage of autologous blood until the scheduled date of care, with the following clarification: Individual benefits must be verified, as coverage may vary by product and/or group. When the transfusion occurs in a participating facility setting, the associated charges for the transfusion are included in the facility reimbursement.

Guidelines

This policy is consistent with Medicare's coverage determination. Autologous blood collection, storage, and transfusion are not considered routine preadmission testing services.

References

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 110.7: Blood transfusions. [CMS Web site]. 12/08/1994. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=110.7&ncd_version=1&basket=ncd%3A110%2E7%3A1%3ABlood+Transfusions. Accessed February 1, 2006. Company benefit contracts.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	N/A
Revenue Codes	N/A

Cross References

Version Effective Date: 05/30/2006