2009-07-22

ASH met with the Centers for Medicare & Medicaid Services (CMS) regarding the background, trends and complexities associated with bone marrow and stem cell transplant services and their impact on reimbursement. Efforts have been in collaboration with the American Association of Blood Banks (AABB), the American Society for Blood and Marrow Transplantation (ASBMT) and the National Marrow Donor Program (NMDP). Issues addressed with CMS include:

• There currently is a single Diagnosis Related Grouping (DRG) for bone marrow transplants covering both autologous and allogeneic bone marrow procedures. There are significant differences in the costs of performing a transplant involving the use of a donor, particularly an unrelated donor, and using the patient’s own bone marrow. An autologous bone marrow transplant is reported under CPT code 38241, Bone marrow or blood-derived peripheral stem cell transplantation, autologous, while an allogeneic procedure is reported under code 38240, bone marrow or blood-derived peripheral stem cell transplantation, allogeneic. To obtain a realistic cost of bone marrow transplants, the organizations suggested that it may be advisable to have two DRGs differentiated between autologous and allogeneic transplants. 

• The recently issued manual instruction states at section 90.3.3 that acquisition costs for allogeneic stem cell transplants – including such costs as NMDP fees, tissue typing, donor evaluation, physician donor evaluation services, costs associated with harvesting procedure, post procedure evaluation of donor and preparation and processing of stem cells – are to be included in the MS-DRG payment for the transplant. However, no comparable instruction has been issued for calculating the APC costs for allogeneic transplants in the out patient setting and is creating confusion.
  
  Subsequent to our meeting, CMS published the proposed Hospital Outpatient Prospective Payment System (HOPPS) rule for 2010 which would classify all allogeneic harvesting and transplant procedures as  procedures that are payable only on an inpatient basis. This is an issue that ASH will want to comment on in the proposed rule in concert with the other organizations interested in this issue.

• In regards to bundling of services from other facilities, there is confusion regarding the obligations of the transplant hospitals to bill for transplant-related services rendered by community hospitals.

• There are circumstances where search and acquisition costs are incurred, but do not result in a transplant due to patient death or other reasons. Current Medicare policy does not permit these services to be billed when a transplant is not performed. The societies noted to CMS that substantial costs are expended related to a donor search and harvesting of transplant tissue from a donor for a specific patient even if the transplant does not ultimately happen. 

The issues noted above and next steps were elucidated in a follow up letter to CMS. ASH, ABMT, AABB and NMDP anticipate that resolving these issues will require ongoing communication with CMS. Initial efforts will include evaluating the data to confirm that there are major differences in costs between allogeneic and autologous transplants. If the relationship is verified by data, the organizations will recommend a DRG change in FY 2011. For additional information, please contact ASH Senior Manager, Policy & Practice, Carol Schwartz at 202-776-0544.

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