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Medicare Reimbursement: Outpatient Final Rule Maintains Current Payment Status Indicators

On November 1, The Centers for Medicare & Medicaid Services (CMS) released the Outpatient Prospective Payment System (OPPS) Final Rule for CY 2018. We are pleased to share that CMS has agreed to maintain assignment of HCPCS code 38205 to payment status indicator “B” and not move forward with their original proposal to change the assignment to status indicator “S.” This change would have allowed donor-related services to be inappropriately billed to their insurance, which is contrary to CMS billing guidance advising that all donor-related services are to be held and billed on the transplant recipient’s claim. The National Marrow Donor Program (NMDP)/Be The Match provided comments to encourage CMS to withdraw their proposal to change the status indicator assignment and had the opportunity to present this issue at the Hospital Outpatient Payment (HOP) Advisory Panel Meeting.

CMS commented in their Final Rule, “After consideration of the public comments we received, we are not finalizing our proposal to change the status indicator assignment for the procedure described by HCPCS code 38205 from ‘B’ to ‘S’ and to assign HCPCS code 38205 to APC 5242.

Read our CY18 OPPS Proposed Rule comment letter.

MAC Local Coverage Article Includes Comprehensive Coverage of Lymphoma for Allo HCT  

Currently there is no mention of lymphoma in the Medicare National Coverage Determination policy for allogeneic HCT (110.23), so coverage is at the discretion of local Medicare Administrative Contractors (MAC).

NGS, the MAC for 10 states, recently issued a Local Coverage Article (LCA) policy for HCT that includes comprehensive coverage of lymphoma for allogeneic HCT. NGS’s jurisdictions include Illinois, Minnesota, Wisconsin, Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. If your transplant center is in one of these states, then your Medicare patients with a diagnosis of lymphoma are able to receive Medicare coverage for HCT. If your center is not in NGS’s MAC, please contact your local MAC to discuss coverage options or consider referring your patient to a center in one of these states.

Review NGS’s coverage policy for HCT and covered diagnosis codes.

Legislation: Bipartisan Bill H.R. 4215 Introduced to Protect Patient Access to HCT

As we shared last week, earlier this month, Representatives Erik Paulsen (MN-03), Doris Matsui (CA-06), Gus Bilirakis (FL-12), and Ron Kind (WI-03) introduced the Protect Access to Cellular Transplant (PACT) Act (HR 4215). If passed into law, this bill would require Medicare to reimburse hospitals for donor search & cell acquisition costs on a reasonable cost basis and separately from the MS-DRG 014 reimbursement, which is approximately $65,000.

Separating reimbursement for donor search & cell acquisition costs from the inpatient stay mirrors Medicare payment policy for organ procurement in solid organ transplant and would allow hospitals to more adequately recoup the costs of providing life-saving HCT for their patients. If you haven’t yet, please ask your Members of Congress to cosponsor this important piece of legislation and protect patient access to HCT.

Learn more about NMDP/Be The Match’s Medicare policy reform efforts

Do you have questions or want to share your experiences regarding Medicare coverage? Please email us at We want to hear from you! 


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