Intricacies of Transplant Physician/Surgeon Coding, Billing, and Reimbursement
While the principles of coding, billing, and reimbursement for transplant physicians and surgeons bear significant overlap with those of all other surgical disciplines, there are sufficient differences to warrant additional comment. More specifically, congressionally mandated regulatory oversight requirements based on the National Transplant Organ Act (NOTA, 1984) that governs transplant practice in the United States have inherently resulted in unique reimbursement methodologies for transplant hospitals that have in turn created a number of mechanisms by which physicians and surgeons can bill and be reimbursed that fall outside standard E&M and CPT coding, billing, and reimbursement constructs. These relate primarily to Medicare patients, but commercial payers, for over two decades, have also instituted different care delivery and reimbursement models consisting of bundled services and payments for transplantation that differ significantly from standard models used in other healthcare disciplines.
KeywordsDeceased Donor Medicare Beneficiary Medicare Part Organ Bank Reimbursement Model
- 1.Medicare program; hospital conditions of participation: requirements for approval and re-approval of transplant centers to perform organ transplantation. Final rule (42 CFR 405, 482, 488, and 498). Fed Regist. 2007;72:15198–280.Google Scholar
- 2.Abecassis MM, Burke R, Cosimi AB, Matas AJ, Merion RM, Millman D, Roberts JP, Klintmalm GB on behalf of the American Society of Transplant Surgeons. Special article: transplant center regulations – a mixed blessing? An ASTS Council viewpoint. Am J Transplant. 2008;8(12):2496–502. doi: 10.1111/j.1600-6143.2008.02434.x.
- 3.Abecassis MM, Burke R, Klintmalm GB, Matas AJ, Merion RM, Millman D, Olthoff K, Roberts JP. American society of transplant surgeons transplant center outcomes requirements – a threat to innovation. Am J Transplant. 2009;9:1279–86. doi: 10.1111/j.1600-6143.2009.02606.x. Epub 2009 Apr 10.CrossRefPubMedGoogle Scholar
- 7.Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP. Medicare’s bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin. Health Aff (Millwood). 2011;30(9):1708–17. doi: 10.1377/hlthaff.2010.0394. PubMed PMID: 21900662; PubMed Central PMCID: PMC4109141.CrossRefGoogle Scholar
- 8.Surgeons and bundled payment models: a primer for understanding alternative physician payment approaches. Chicago: The American College of Surgeons/Division of Advocacy and Health Policy; 2013.Google Scholar
- 10.Abecassis M, Alphs Jackson H, Walsh B. Bundled payment: managing risk by managing variability. NEMJ catalyst article. December 29, 2015. http://catalyst.nejm.org/bundled-payment-managing-risk-by-managing-variability/.