Intricacies of Transplant Physician/Surgeon Coding, Billing, and Reimbursement

Abstract

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.