Claim Payment Policy

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Title:

Organ and Tissue Recovery from a Cadaveric Donor and Associated Services

Policy #:

01.00.03b

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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.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service. 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 organ and tissue recovery (procurement, retrieval) from a cadaveric donor and associated services. For information on policies related to organ transplantation, refer to the Cross References Table in this policy.

Description

Organ and tissue recovery is part of the organ transplant process. Recovery of organs and tissues for transplantation can be performed on living and nonliving (ie, cadaveric) donors. Cadaveric donors are those whose organs or tissues are excised after death has been determined for implantation into a recipient. Determination of death is made using either cardiopulmonary or neurological criteria. The donor for whom cardiopulmonary criteria is used to determine death is referred to as a non-heart-beating donor. The donor for whom neurological criteria is used to determine death is referred to as having experienced brain death. The reimbursement process for organ and tissue recovery is managed by an organ procurement organization (OPO). According to TransWeb, a nonprofit educational Web site, OPOs are not-for-profit organizations that are responsible for the identification and care of organ donors; organ retrieval, preservation, and transportation; and data follow-up regarding cadaveric organ donors.

Policy

Recovery of organs and tissues from a cadaveric donor (eg, surgical transplant team charges) and associated services (eg, physiologic support of the cadaveric donor) are managed directly by the organ procurement organization (OPO). The transplant recipient, the Company, and the transplant hospital have neither primary nor direct responsibility for reimbursement to the provider for such services.

Guidelines

ORGAN PROCUREMENT ORGANIZATIONS (OPOs) Information regarding organ and tissue recovery from a cadaveric donor and associated services can be obtained by contacting the appropriate regional organ procurement organization (OPO): DELAWARE, EASTERN PENNSYLVANIA, SOUTHERN NEW JERSEY Gift of Life Donor Program 401 North 3rd Street Philadelphia, PA 19123-4101 http://www.donors1.org NEW JERSEY New Jersey Organ and Tissue Sharing Network 841 Mountain Avenue Springfield, NJ 07081 http://www.sharenj.org SOUTHERN NEW YORK, CENTRAL AND WESTERN PENNSYLVANIA, WEST VIRGINIA Center for Organ Recovery & Education (CORE) 204 Sigma Drive RIDC Park Pittsburgh, PA 15238 http://www.core.org

References

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 11: End stage renal disease (ESRD). §140.15: Provider costs related to cadaver kidney excisions. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf. Accessed February 23, 2009. Institute of Medicine (IOM). Non-Heart-Beating Organ Transplantation: Practice and Protocols. [The National Academies Press Web site]. Available at: http://www.nap.edu/catalog/9700.html#toc. Accessed February 25, 2009. Organ Procurement and Transplantation Network (OPTN). §3.1: Definitions. [OPTN Web site]. 02/21/08. Available at: http://www.optn.org/PoliciesandBylaws2/policies/pdfs/policy_3.pdf. Accessed February 23, 2009. Reich DJ MD. Non-heart-beating donor liver transplantation. [Medscape Web site]. 05/13/04. Available at: http://www.medscape.com/viewarticle/477529 [via subscription only]. Accessed February 25, 2009. Smith SL MN PhD. Organ and tissue donation and recovery. [Medscape Web site]. 03/28/03. Available at: http://www.medscape.com/viewarticle/451208 [via subscription only]. Accessed February 23, 2009. University of Michigan Transplant Center. Glossary: organ procurement organization (OPO). [TransWeb.org Web site]. Available at: http://www.med.umich.edu/trans/transweb/journey/recip_journey/glossary/blue/opo.html. Accessed February 23, 2009. US Department of Health and Human Services. Advisory Committee on Organ Transplantation (ACOT). Fall meeting minutes. Reimbursement for increased costs of DCD/ECD organs. [OrganDonor.gov Web site]. 11/01/05. Available at: http://www.organdonor.gov/research/acot11_2005.htm. Accessed February 23, 2009. US Department of Health and Human Services. Terms and topics A-Z. [OrganDonor.gov Web site]. Available at: http://organdonor.gov/terms.htm. Accessed February 23, 2009.

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	01990 THE FOLLOWING SERVICES ARE COORDINATED BY THE ORGAN PROCUREMENT ORGANIZATION (OPO): 32850, 33930, 33940, 44132, 47133, 48550, 50300
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	THE FOLLOWING SERVICE IS COORDINATED BY THE ORGAN PROCUREMENT ORGANIZATION (OPO) S2055: Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor
Revenue Codes	THE FOLLOWING SERVICE IS COORDINATED BY THE ORGAN PROCUREMENT ORGANIZATION (OPO) 812: Acquisition of Body Parts - Cadaver Donor

Cross References

Version Effective Date: 01/10/2007