For Medicare outpatients, how are blood products paid?
As described by the Centers for Medicare & Medicaid Services (CMS), codes in the following categories are paid under a reasonable-charge basis:
• Blood products
• Transfusion medicine
• Reproductive medicine.
As CMS states in transmittal 3687CP, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update, which is 1 percent for 2017.
When these services are performed for hospital-based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment
is made under the hospital outpatient prospective payment system (OPPS).
A list of codes paid and other details of this payment can be found in transmittal R3687CP at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3687CP.pdf.