Anesthesia Coding Alert

Question: Should I code anesthesia for weaning a patient from ECMO (extracorporeal membrane oxygenation) with CPT 36822?

Washington Subscriber

Answer: Just as it is rare to wean a patient from a ventilator under anesthesia, providers don't wean patients from ECMO under anesthesia unless there are highly unusual circumstances. The process can take days or weeks and is usually done with sedation.

Weaning is not the same thing as initiating ECMO. Insertion of cannulas is something the provider needs do to start ECMO. Once ECMO is started, the patient can be sedated if necessary and weaned when the problem that required ECMO is no longer life-threatening. The surgeon inserts the ECMO cannula; another physician (usually an intensivist) manages the ECMO.

The surgeon bills 36822 (Insertion of cannula[s] for prolonged extracorporeal circulation for cardiopulmonary insufficiency [ECMO] [separate procedure]) to start ECMO, which cannot be done without the cannula. Daily management codes are 33960 (Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial 24 hours) and 33961 (... each additional 24 hours [List separately in addition to code for primary procedure]), but only one physician can bill the 33960/33961 codes per day.

The cannula has to be placed only once. Once the cannulas are placed ECMO is started and can continue for days.

The anesthesia crosswalk for 36822 offers the following options:

• 01270 -- Anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified

• 00350 -- Anesthesia for procedures on major vessels of neck; not otherwise specified

• 00560 --Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator.

The anesthesia code depends on where on the body the provider inserted the cannula.

FYI: You would append modifier 23 (Unusual anesthesia) only if your anesthesiologist used general anesthesia.