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National Coverage Determination (NCD)

Blood Transfusions

110.7

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Tracking Information

Publication Number
100-3
Manual Section Number
110.7
Manual Section Title
Blood Transfusions
Version Number
1
Effective Date of this Version
12/08/1994
Ending Effective Date of this Version
Implementation Date
12/08/1994
Implementation QR Modifier Date

Description Information

Benefit Category
Inpatient Hospital Services
Outpatient Hospital Services Incident to a Physician's Service


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Blood transfusions are used to restore blood volume after hemorrhage, to improve the oxygen carrying capacity of blood in severe anemia, and to combat shock in acute hemolytic anemia.

A. Definitions

1. Homologous Blood Transfusion

Homologous blood transfusion is the infusion of blood or blood components that have been collected from the general public.

2. Autologous Blood Transfusion

An autologous blood transfusion is the precollection and subsequent infusion of a patient's own blood.

3. Donor Directed Blood Transfusion

A donor directed blood transfusion is the infusion of blood or blood components that have been precollected from a specific individual(s) other than the patient and subsequently infused into the specific patient for whom the blood is designated. For example, patient B's brother predeposits his blood for use by patient B during upcoming surgery.

4. Perioperative Blood Salvage

Perioperative blood salvage is the collection and reinfusion of blood lost during and immediately after surgery.
Indications and Limitations of Coverage

B. Policy Governing Transfusions

For Medicare coverage purposes, it is important to distinguish between a transfusion itself and preoperative blood services; e.g., collection, processing, storage. Medically necessary transfusion of blood, regardless of the type, may generally be a covered service under both Part A and Part B of Medicare. Coverage does not make a distinction between the transfusion of homologous, autologous, or donor-directed blood. With respect to the coverage of the services associated with the preoperative collection, processing, and storage of autologous and donor-directed blood, the following policies apply.

1. Hospital Part A and B Coverage and Payment

Under §1862(a)(14) of the Act, non-physician services furnished to hospital patients are covered and paid for as hospital services. As provided in §1886 of the Act, under the prospective payment system (PPS), the diagnosis related group (DRG) payment to the hospital includes all covered blood and blood processing expenses, whether or not the blood is eventually used.

In a situation where the hospital operates its own blood collection activities, rather than using an independent blood supplier, the costs incurred to collect autologous or donor-directed blood are recorded in the whole blood and packed red blood cells cost center. Because the blood has been replaced, Medicare does not recognize a charge for the blood itself. Under PPS, the DRG payment is intended to pay for all covered blood and blood services, whether or not the blood is eventually used.

Under its provider agreement, a hospital is required to furnish or arrange for all covered services furnished to hospital patients. Medicare payment is made to the hospital, under PPS or cost reimbursement, for covered inpatient and outpatient services, and it is intended to reflect payment for all costs of furnishing those services.

2. Nonhospital Part B Coverage

Under Part B, to be eligible for separate coverage, a service must fit the definition of one of the services authorized by §1832 of the Act. These services are defined in 42 CFR 410.10 and do not include a separate category for a supplier's services associated with blood donation services, either autologous or donor-directed. That is, the collection, processing, and storage of blood for later transfusion into the beneficiary is not recognized as a separate service under Part B. Therefore, there is no avenue through which a blood supplier can receive direct payment under Part B for blood donation services.

C. Perioperative Blood Salvage

When the perioperative blood salvage process is used in surgery on a hospital patient, payment made to the hospital (under PPS or through cost reimbursement) for the procedure in which that process is used is intended to encompass payment for all costs relating to that process.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
72
Revision History

11/1994 - Clarified coverage and payment policies. Effective date 12/08/1994. (TN 72)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Blood Transfusions 1 12/08/1994 - N/A You are here
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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