Retrospective Data Review of Blood and Marrow Transplant (BMT) Medicare Coding to Analyze Coverage and Reimbursement Claims

The number of hematopoietic cell transplants (HCT) for Medicare beneficiaries has dramatically increased, heightening the need to address Medicare coverage and reimbursement. Previous analysis of CMS claims data by ASBMT and NMDP suggested variability by HCT programs (HCTP) in coding and billing. Addressing these issues may be critical to ensure financial solvency for HCTP and continued HCT access for Medicare beneficiaries. 

The Sarah Cannon Blood Cancer Network (SCBCN), consisting of 5 FACT accredited HCTP, analyzed Medicare claims data submitted by SCBCN between 1/1/11 and 12/31/11. 120 HCT were performed on 119 patients (pts): 69 men and 50 women, median age 67 years (range 28-79) with Multiple Myeloma (62), Lymphoma (35), Acute Leukemia (17) and other (5). There were 23 allogeneic (allo) HCT (MS-DRG-14), 2 of which were outpatient with an average length of stay (LOS) of 30 days (0-123) for related and 25 days (5-55) for unrelated; 12/23 were < 20 days.  Inpatient coding for autologous (auto) HCT was split among three MS-DRG because of a change in 2012 from MS-DRG- 15 (71) and to MS-DRG 16—with complication/comorbidity (cc) (18) and MS-DRG 17—without cc (8) with average LOS 18 days (2-39); 55/97 were <20 days. Of 18 pts assigned DRG16, all appeared to have codes supporting increased complexity. Of 8 pts assigned DRG17, 5 had codes that might have supported billing under DRG 16. Among 23 allo pts, 7 were missing the code defining donor source as related or unrelated including both patients who received outpatient allo HCT. Revenue code 819, which reports charges for donor cell acquisition, was reported in 18 cases with a 40-fold variance in range of charges. Interestingly, this code was also submitted in 46 of 97 auto cases.

Conclusion:  Significant opportunities may exist for using the proper MS-DRG for auto pts (which has substantial revenue implications) and the use of revenue code 819 for allo HCT (which has substantial implications for future rate setting). Programs can significantly increase future payment rates by understanding their current Medicare billing practices and identifying opportunities for improvement.  Further investigation will focus on estimation of costs as compared with reimbursement for Medicare beneficiaries.