(ECMO) Extracorporeal Membrane Oxygenation (or)
(ECLS) Extracorporeal life support services
ECMO/ECLS provide Cardiac and respiratory support to the heart and/or lungs by continuously pumping a patient’s blood out of the body to an oxygenator (membrane lung), where
1. Oxygen is added
2. Co2 is removed
3. Blood is warmed before return to the patient’s body
There are two methods in ECMO/ECLS
1. Veno-arterial extracorporeal life support (Support heart and lung)
One cannula is placed in a large vein and one cannula in a large artery. (Two cannulas)
2. Veno-venous extracorporeal life support (Lung support only)
One or two cannulas are placed in a vein.
Initiation of ECMO/ECLS circuit and setting parameters is performed by the physician and involves determining the necessary ECMO/ECLS device components, blood flow, gas exchange, and other necessary parameters to manage the circuit.
The daily management of the ECMO/ECLS circuit and monitoring parameters requires physician oversight to ensure that specific features of the interaction of the circuit and parameters include management of blood flow, oxygenation, CO2 clearance by the membrane lung, systemic response, anticoagulation and treatment of bleeding, and cannula positioning, alarms and safety.
Once the patient’s heart and lung function have sufficiently recovered, the physician will wean the patient from the ECMO/ECLS circuit and finally decannulate the patient.
Daily overall management of the patient should be separately reported with appropriate E&M codes (Observation/Inpatient/Critical care services).
Multiple physicians involve in ECMO/ECLS procedures. If the same physician provides any or all the services, report appropriate codes (Cannula insertion, initiation, daily patient management) Note: Daily management of ECMO/ECLS and repositioning services may not be reported on the same day of initiation services by the same or different physician.
Insertion of cannula codes:
Peripheral (arterial and/or Venous)
· CPT 33951 – Below 5 yrs
· CPT 33952 – Above 6 yrs
Open (Arterial and/or Venous)
· CPT 33953 – Below 5 yrs
· CPT 33954 – Above 6 yrs
Sternotomy or Thoracotomy (Arterial and/or Venous)
· CPT 33955 – Below 5 yrs
· CPT 33956 – Above 6 yrs
Initiation of ECMO
· CPT 33946 – Veno Venous
· CPT 33947 – Veno Arterial
Daily Management (each day) of ECMO
· CPT 33948 – Veno venous
· CPT 33949 – Veno Arterial
Reposition of Cannulae
· CPT 33957 – Percutaneous, Below 5 yrs
· CPT 33958 – Percutaneous, Above 6 yrs
· CPT 33959 – Open, Below 5 yrs
· CPT 33962 – Open, Above 6 yrs
· CPT 33963 – Sternotomy or Thoracotomy, Below 5 yrs
· CPT 33964 – Sternotomy or Thoracotomy, Above 6 yrs
Removal of cannulae
· CPT 33965 – Percutaneous, Below 5 yrs
· CPT 33966 – Percutaneous, Above 6 yrs
· CPT 33969 – Open, Below 5 yrs
· CPT 33984 – Open, Above 6 yrs
· CPT 33985 – Sternotomy or Thoracotomy, Below 5 yrs
· CPT 33986 – Sternotomy or Thoracotomy, Above 6 yrs
Coding Guidelines:
· Repositioning of the ECMO/ECLS cannula at the same session as insertion is not separately reportable.
· Replacement of ECMO/ECLS cannula in the same vessel should only be reported using the insertion code (33951-33956)
· If the cannula is removed from one vessel and new cannula are placed in the different vessel – then report both Removal (33965 - 33969, 33984 - 33986) and Insertion (33951 - 33956)
· Extensive repair or replacement of an artery may be additionally reported (35266, 35286, 35371 and 35665)
NOTE: Fluoroscopic guidance used for cannula repositioning (33957, 33958, 33959, 33962, 33963, 33964) is included in the procedure, should not be separately reported.
Daily Management codes (33948 and 33949) should not be reported on the same day as initiation of ECMO (33946 or 33947)
Initiation codes should not be coded on the repositioning codes.
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Cardiac Assist
Insertion of ventricular assist device (VAD)
1. Percutaneous – 33990, 33991
2. Transthoracic – 33975, 33976, 33979 (Device Location: Intracorporeal or Extracorporeal)
Percutaneous
· CPT 33990 – Arterial access only
· CPT 33991 – Arterial and venous access
Transthoracic
· CPT 33975 – Single ventricle, Extracorporeal
· CPT 33976 – Biventricular, Extracorporeal
· CPT 33979 – Single Ventricle, Intracorporeal
Coding Guidelines:
1. Open arterial exposure (34714, 34715, 34716, 34812, 34820, 34833, and 34834) to facilitate percutaneous ventricular assist device insertion (CPT 33990 (or) 33991) may be reported separately.
2. Extensive repair or replacement of an artery may be additionally reported (Eg: 35226 or 35286)
Removal of a ventricular assist device:
Includes removal of the entire device, including the cannula
· CPT 33977 – Extracorporeal, single ventricle
· CPT 33978 – Extracorporeal, Bi-ventricle
· CPT 33980 – Intracorporeal, single ventricle
· CPT 33992 – Percutaneous VAD
Note: Removal of percutaneous VAD on the same day of insertion but the separate and distinct session, use modifier 59 with CPT’s (Removal of a percutaneous VAD at the same session as insertion is not separately reportable).
Repositioning of a ventricular assist device
· CPT 33993 – Percutaneous VAD
Note: Append modifier 59 with CPT 33993 is performed on the same day of insertion but on a different session. (The same session as insertion is not separately reportable)
Replacement of Ventricular assist device pump:
Includes the
1. Removal of pump
2. Insertion of a new pump
3. Connection
4. De-airing
5. Initiation of the new pump
· CPT 33981 – Extracorporeal, single or biventricular
· CPT 33982 – Intracorporeal, single ventricle, without Cardiopulmonary bypass
· CPT 33983 – Intracorporeal, single ventricle, with Cardiopulmonary bypass
Replacement of entire implantable ventricular assist device system (Pump and cannulas)
There is no specific code hence use insertion codes
1. Transthoracic - CPT 33975, 33976, 33979
2. Percutaneous - CPT 33990, 33991
Note: Removal of the VAD being replaced is not reported separately.
Replacement of percutaneous ventricular assisted device is reported using implantation codes (33990, 33991) removal is not reported separately.
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Intra – Aortic balloon assist device
Insertion of Intra aortic balloon assist device
· CPT 33967 – Percutaneous
· CPT 33970 – Open, Femoral
· CPT 33973 – Ascending aorta
Removal of Intra aortic balloon assist device
· CPT 33968 – Percutaneous
· CPT 33971 – Open, Femoral
· CPT 33974 – Ascending aorta
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