Cardiology Coding Alert

Know the rules when multiple physicians are involved.

Extracorporeal membrane oxygenation (ECMO) can be challenging to report because you must know numerous details including what kind of ECMO your physician performed, how many physicians were involved, and what type of cannulas they used. If you submit incorrect claims, you risk denials.

Take a look at what you need to know to always report clean ECMO claims.

Focus on 2 Types of ECMO Procedures

There are two different types of ECMO procedures, said Louis Jimenez, RRT, CHT, in his presentation “Extracorporeal Membrane Oxygenation – ECMO” at AAPC’s Healthcon 2023 conference in Nashville, Tenn. They are veno-venous (VV) and veno-arterial (VA).

1. Veno-venous (VV) ECMO: VV ECMO takes blood from a vein and returns it to a vein. VV ECMO requires one or two cannula(e), which your physician will place in a vein.

VV ECMO is utilized for respiratory support, namely oxygenation and CO2 removal, according to Jimenez. Report 33946 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous) for VV ECMO.

2. Veno-arterial (VA) ECMO: The second method of ECMO is VA, which takes blood from a vein and returns it to an artery. VA ECMO supports both the heart and the lungs. VA ECMO also requires that your physician place two cannula(e) — one in a large vein and one in a large artery.

Report 33947 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-arterial) for VA ECMO, per Jimenez.

Don’t miss: Codes 33946 and 33947 are examples of codes that are reported for the initial cannulation and repositioning, removing, or adding of cannula(e) while the ECMO is supporting the patient.

A physician must perform codes 33946 and 33947. During these services, the physician will determine the necessary ECMO device components, the blood flow, the gas exchange, and any other necessary parameters to manage the circuit, according to CPT^®.

“ECMO is used in critically ill patients who have severe cardiopulmonary insufficiency,” says Robin Peterson, CPC, CPMA, manager of professional coding and compliance services, Pinnacle Enterprise Risk Consulting Services, LLC in Centennial, Colorado. “With ECMO, the patient’s blood is continuously circulated from the body through the ECMO machine. The ECMO machine removes the carbon dioxide from the blood and oxygenates it and returns it back to the patient, temporarily replacing heart or lung function.”

Report 33948, 33949 for ECMO Daily Management

You should report either 33948 (Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-venous) or 33949 (… veno-arterial) for daily ECMO management, said Jimenez. These are codes you will report every day.

Daily ECMO management requires your physician’s oversight to ensure that the specific features of the interaction of the circuit with the patient are met. This includes the following:

• Management of blood flow;
• Oxygenation;
• CO₂ clearance by the membrane lung;
• Systemic response;
• Anticoagulation and treatment of bleeding; and
• Cannula positioning, alarms, and safety.

Keep An Eye Out For These Cannula Insertion Codes

With ECMO, your physician will use different types of cannulas, Jimenez said.

VV ECMO peripheral cannulas: These include the following:

• Jugular vein — A larger length cannula with ports
• Femoral vein — A larger length cannula with ports
• Dual lumen cannula — This consists of one port that has both distal and proximal drainage (above and below) the right atrium for venous drainage and a second port to return oxygenated blood into the right atrium, Jimenez said.

VA ECMO peripheral cannulas: These include the following:

• Femoral artery
• Reperfusion cannula for the leg on the same side where the femoral cannula was placed. The reperfusion cannula is utilized to assure non-interrupted circulation of the leg.

“ECMO is an invasive procedure that requires cannula placement into the venous circulation as well as the arterial circulation,” Jimenez said.

These cannulas are introduced into the peripheral circulation, as well as into myocardial structures, Jimenez explained. Throughout the ECMO process, these cannulas may need repositioning or re-insertion. Codes 33957 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)) and 33958 (… ; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed)) are the codes used when the repositioning of a peripheral cannula is performed.

Central cannulas: Central cannulas are open chest procedures, Jimenez said. This type of insertion requires a sternotomy and/ or thoracotomy procedures. Report 33955 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age) and 33956 (… insertion of central cannula(e) by sternotomy or thoracotomy, 6 years and older) for this type of procedure.

Follow This Guidance for Different Physicians

If your physician is one of many involved in an ECMO/ECLS procedure, ensure you know how to appropriately bill your provider’s portion.

For example, when multiple physicians are involved in ECMO/ ECLS, one physician may manage the circuit and patient-related issues like anticoagulation and another physician may manage the patient’s overall medical condition and underlying disorders — on a daily basis. These physicians are usually of different specialties, and significant physician team interaction is usually necessary.

If the same physician provides any or all of the services for placing a patient on an ECMO/ECLS circuit, they can report the appropriate codes for the specific services that they performed, per the CPT^® guidelines. These codes include 33951-33956 for the cannula(e) insertion; 33946 or 33947 for the ECMO/ECLS initiation; and the appropriate evaluation and management (E/M) code for overall patient management.

The same or different individuals may not report 33948 or 33949 for ECMO/ECLS daily management and 33957-33964 for repositioning services on the same day as codes 33946 or 33947, according to the guidelines.

Supporting nonphysician personnel: Supporting nonphysician personnel, such as ECMO/ECLS specialists, cardiac perfusionists, respiratory therapists, and specially trained nurses, may be required to work on the ECMO/ECLS patients, depending upon the particular patient’s condition and the specific type of circuit.

Don’t miss: “Replacement of an ECMO cannula in the same vessel should be reported with the insertion code (33951- 33956),” Peterson says. “However, if cannula is removed from one vessel and inserted into a different vessel you would report the removal (33965, 33966, 33969, 33984, 33985, or 33986) and insertion codes (33951-33956). You may additionally report extensive repair of an artery when performed (35266, 35286, 35371, or 35665). If fluoroscopy is used during repositioning, it is considered included in the procedure.”