Coding for ECMO/ECLS in Critical Care

2016 - 6 December – Survive and Thrive
Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA
Learn about coding for ECMO/ECLS in Critical Care.

​Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a cardiopulmonary bypass technique. It provides long-term cardiac or respiratory support in patients with respiratory or cardiac insufficiency. Physicians often use this technology with newborns. Indications for its use include meconium aspiration, pulmonary hypertension and congenital diaphragmatic hernia in newborns. Pediatric patients with acute respiratory distress syndrome or pneumonia and adult patients who have undergone cardiac surgery or have other life-threatening problems also benefit from this technique.

ECMO is an intensive treatment currently used in facilities to support patients with respiratory or cardiac failure who are unresponsive to conventional therapeutic interventions. Some causes of respiratory failure in neonates include respiratory distress syndrome (hyaline membrane disease), meconium aspiration syndrome and congenital diaphragmatic hernia. Some causes of respiratory and cardiac failure in post-neonatal children (at least one month old) and adults include pneumonia, septic shock, congenital heart disease, cardiomyopathy, severe burns and pulmonary hemorrhage.

There are two methods that can be used to accomplish ECMO/ECLS, venoarterial, which supports both heart and lungs where two cannulae are placed—one in a large vein and one in a large artery, and venovenous, for lung support, which requires one or two cannulae placed in a vein.

Current Procedural Terminology (CPT) codes1 are
selected based on the following criteria:
• Age of patient
• Type (venoarterial vs. venovenous)
• Procedure
  - Cannula insertion
  - Cannula repositioning
  - Decannulation removal
  - Other cannula procedures
• Method
  - Percutaneous
  - Open
  - Sternotomy/thoracotomy

The following CPT codes are reported for ECMO/ECLS:
Initiation


CPT codes 33946–33947 include:
• Determining the necessary ECMO/ECLS device
component
• Blood flow
• Gas exchange
• Parameters to manage the circuit

CPT codes 33951–33956 are reported for insertion or
replacement of the ECMO/ECLS cannula in the same
vessel. Codes are selected based on the patient’s age and
the approach:
• Percutaneous
• Open
• Sternotomy/thoracotomy

Subsequent Management and Repositioning

CPT codes 33948 and 33949 are reported for daily management of the ECMO/ECLS circuit and monitoring parameters, which requires physician oversight to ensure that specific features of the interaction of the circuit with the patient are met. If critical care services are provided on the same date of service, they can be reported separately as management that is not bundled under the National Correct Coding Initiative (NCCI).

These management codes include:
• Daily management of circuit and parameters
• Blood flow
• Oxygenation
• CO2 clearance by the membrane lung
• Systemic response
• Anticoagulation and treatment of bleeding
• Cannula position
• Alarms and safety

Coding tip: Fluoroscopic guidance is included in the cannulae repositioning and is not reported separately.

Decannulation
CPT codes for decannulation (removal): If a cannula is removed from one vessel and a new cannula is placed in a diffirent vessel, report the removal using a decannulation code and an insertion code (33951–33956), depending on patient’s age and the approach. Extensive repair of an artery (35266, 35386, 35371, and 35665) may be reported in addition to these procedures.


Additional procedures that can be reported in addition to the ECMO/ECLS codes include:

Other Cannula Procedures
• +33987: Arterial exposure with creation of graft conduit to facilitate arterial perfusion for ECMO/ECLS (add-on code)
• 33988: Insertion left heart vent by thoracic incision for ECMO/ECLS
• 33989: Removal left heart vent by thoracic incision for ECMO/ECLS

CPT codes 33987–33989 are not bundled with the other ECMO procedures under NCCI and can be reported as additional procedures with ECMO insertion, repositioning or decannulation. Note that a code with a + sign (e.g., 33987) is an add-on code and is reported secondary to a primary procedure.

Coding Guidance
Critical care services as well as other daily management evaluation and management services are not included in the ECMO/ECLS procedures 33946, 33947, 33948, and 33949.

CPT codes 33951–33989 are bundled under NCCI. Modifier 25 is allowed if the procedure is significantly separately identifiable from management of critical care services, adult, neonate, or pediatrics. Be certain that documentation is clear that the critical care service is separately identifiable in the documentation as well as ECMO/ECLS daily management.

ECMO/ECLS daily management (33948 or 33949) and repositioning procedures may not be reported on the same date of service as the initiation (33946–33947) services by either the same or different practitioners. The ECMO/ECLS daily management codes are not bundled into the critical care evaluation and management care codes.

Repositioning of cannulae at the same session as insertion is bundled and not separately reportable. When repositioning is done at a different operative session, a modifier is required, depending on the circumstance. Fluoroscopic guidance used for cannula repositioning is included in the procedure and should not be separately reported.

Append modifier 25 (significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare practitioner on the same day of the procedure or other service) to the critical care codes when performing ECMO procedures on the same date of service.

Many times, multiple physicians, usually of different specialties, are involved in the care and management of ECMO/ECLS procedures. If a physician provides parts of each service, daily management, critical care services, cannula insertion, repositioning, decannulation, or other cannula procedures, each would report the procedure he/ she individually provided.

Be sure to document the diagnosis code that will prove medical necessity. Many payers have medical policies that list ICD-10-CM codes that support medical necessity for neonates, pediatric patients and adults. It is important to reference these policies to understand what conditions will allow payment for ECMO/ECLS.

 Documentation must be clear and must differentiate management of critical care services from ECMO/ECLS management and/or procedures on the same date of service.

Additional Resources
Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services Manual
System and other CMS publications and services
American Medical Association’s CPT Assistant
Newsletter
National Correct Coding Initiative
Regence Blue Cross Blue Shield ECMO/ECLS medical
policy
Aetna ECMO/ECLS medical policy
Paramount Health Care ECMO/ECLS medical policy

 

References
1. American Medical Association. Current Procedural Terminology (CPT)Chicago, IL: American Medical Association; 2016 and 2017.