Reimbursement information

This Reimbursement Resource website is a tool to help understand the U.S. health care insurance environment for cell processing and ex vivo T cell depletion in allogeneic transplantation.

While payers generally reimburse for stem cell transplantation, it is the patient specific information that often dictates coverage in each individual case. This website provides general guidance regarding steps to support appropriate reimbursement and patient access to ex vivo T cell depletion methods.

Important components of reimbursement

As preparation for reviewing the remainder of this website, it is valuable to understand several standard concepts of reimbursement. Before any product can be deemed "reimburseable," there must be three components in place within a payer:

  1. Coverage: Every patient’s billing situation is unique with regard to the patient’s health plan and scope of benefits. Due to the highly varied and dynamic nature of health care reimbursement, we recommend that you verify each patient’s specific plan policies for submitting claims for allogeneic stem cell transplantation. 
  2. Coding: Insurance codes must be in place to allow a provider to identify the procedures used in stem cell therapy. Both private insurance payers and the U.S. government use a series of numeric codes that identify a procedure or treatment given to a specific patient. 
    • APC's (Ambulatory Payment Classifications) are the United States Government's method of paying for services for the Medicare patient. APCs are an outpatient prospective payment system applicable only to hospitals. Additionally, Health care Common Procedure Coding System numbers (HCPCS Codes) are codes used by Medicare and monitored by the Centers for Medicare and Medicaid Services (CMS). They are based on the Current Procedural Technology (CPT) codes developed by the American Medical Association.  These HCPCS codes are designed to provide a consistency between the Medicare and private payer coding systems.
    • CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient, including medical, surgical and diagnostic services. They are then used by private insurers to determine the amount of reimbursement that a practitioner will receive for a given procedure. Since hospitals and payers use the same codes to mean the same thing, they ensure uniformity.  CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded.
  3. Payment: Payment methodologies continue to evolve in stem cell transplantation. Once the patient's allotransplant has been approved, there are four basic ways in which payment is made in accordance with a patient’s private insurance:
    1. Case rate
    2. Per diem
    3. Based on a percentage of billed charge
    4. Based on a percentage of the Medicare Diagnostic-Related Groups.

Please refer also to downloads and references for more information on reimbursement tools and society websites.

Medicare

In October of 2010, the Centers for Medicare and Medicaid Services  (CMS) created separate Diagnostic-Related Groups (DRGs) to delineate inpatient coverage between allogeneic and autologous transplants.

As of October 2010, the DRG used for coding inpatient allogeneic transplants is DRG 014. (Previously, autologous and allogeneic patients had been grouped into MS-DRG 009) For complete information regarding the Medicare DRG’s and inpatient coding go to the Dept. of HHS Medicare Reimbursement website.

The outpatient transplantation code for reimbursement of allogeneic-related transplantation is CODE 38240. Though this code is specific to allogeneic-related transplant settings, it is combined with the allogeneic unrelated code for the Ambulatory Procedure Code APC 112.

Additional information regarding Medicare and Medicaid reimbursement may be found by following the link: www.cms.hhs.gov.

In 2008, Medicare began to recognize commonly used CPT codes applicable to inpatient allogeneic transplants. Click here for a list of codes typically used in stem cell transplantation for Acute Myeloid Leukemia.

Additional information regarding coding and billing may also be found in the websites of various societies involved in stem cell transplantation.  These include:

If you have an AML patient that qualifies for treatment and is covered by Medicare or Medicaid, click here for a template that may be used to facilitate this coverage discussion.

Private payers

Private health plans are funded by commercial insurance companies. They finance health care either for a particular company’s employees or for individuals who purchase a health plan on their own. Today most people with private health insurance belong to some type of managed care plan, although a few still buy private insurance for service coverage on their own.
Private insurance providers use the system called current procedural terminology (CPT) codes devised by the American Medical Association in 1966. Like their government counterpart, CPT codes communicate to the patient's insurance company what medical, surgical and diagnostic services were performed by medical personnel.

Click here for a list of codes typically used in stem cell transplantation for Acute Myeloid Leukemia.
Additional information regarding coding and billing may also be found in the websites of various societies involved in stem cell transplantation.  These include:

If you have an AML patient that qualifies for treatment and is covered by private insurance, click here for an template that may be used to facilitate this coverage discussion.

Additionally, here is a list of forms and internal documents you might need to submit to the patient’s insurance company in order to obtain authorization to use the CliniMACS® CD34 Reagent System

  • statement / form of medical necessity
  • health plan’s required pre-authorization form
  • heath care provider’s charts and notes

Appeals

If your transplant program has been denied reimbursement of ex vivo T cell depletion procedures by a private payer, you can appeal this decision. Here is what you can do:

  • Understand why the claim has been denied. This should be in the health plan’s letter of denial or the patient’s explanation of benefits letter.
  • Complete and submit the required appeal forms and documents to the health plan before the appeal deadline.
  • Follow up with the appeals department. Usually this can be done within one week of submitting an appeal package.

Click here to view or download a sample letter that may be used to support an appeal for insurance reimbursement if coverage has been denied.