Cardiology Coding Alert

Hint: Always state why the cardio/respiratory and hemodynamic support is being established.

In the article “Bolster ECMO/ECLS Skills With This Primer,” found in Cardiology Coding Alert Vol 22, No. 6, you learned all about the two methods of prolonged extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) and the differences between daily ECMO/ECLS management and daily overall management.

CPT^® offers extensive guidelines and rules for ECMO/ECLS, so it can be difficult to remember them all. You must also know what codes to submit for ECMO/ECLS initiation, how to report for multiple physicians, and what type of medical documentation you need.

Read on to learn even more about ECMO/ECLS.

Depend on These Codes for ECMO/ECLS Initiation

Initiation of the ECMO/ECLS circuit involves deciding which device components are correct for the patient, the blood flow, gas exchange, and any other necessary parameters.

The physician performing this service chooses between the following codes:

• 33946 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous)
• 33947 (… initiation, veno-arterial).

Turn to 33948, 33949 for Daily ECMO/ECLS Management

To report daily ECMO/ECLS management, you will submit either 33948 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-venous) or 33949 (… veno-arterial).

Once the ECMO cannulation has been completed/established, it is equally important to document pump flow rate, assess pump settings, confirm gas line pop-off setting is appropriate for circuit size, assess cannula for correct placement and for evidence of bleeding, saturation rates, to name a few, says Julie-Leah J. Harding, CPC, CPMA, CEMC, CCC, CRC, CPEDC, RMC, PCA, CCP, SCP-ED, CDIS, AHIMA-approved ICD-10 trainer and ambassador and director of revenue operations at Boston Children’s Hospital in Boston, Massachusetts.

Remember: “Be sure to state during ECMO initiation and then during daily management that flows are appropriate (note changes) and circuits are functioning properly,” Harding adds.

ECMO/ECLS Used for Pediatric and Adult Patients

“Extracorporeal membrane oxygenation (ECMO) has normally gravitated to the pediatric neonate populous; however, here in a children’s hospital where we treat serious congenital heart/lung anomalies/conditions, as well as treat these patients well into adulthood, ECMO is used effectively in various ages,” Harding says.

The purpose is to bridge these complex patients to their next repair, transplant, and or the need to isolate to allow the body to recuperate, according to Harding.

“Neonates ages 0 to 28 often need more time for heart lung development, and ECMO management allows for the delicate treatment plans to ensue, Harding explains. “The hope, too, is to ensure the infant can gain weight, which is vital.”

Multiple Physicians Involved? Do This

Multiple physicians are usually involved during ECMO/ECLS procedures, per the CPT® guidelines. “Different physicians may insert the cannula(e) and initiate ECMO/ECLS, manage the ECMO/ECLS circuit, and decannulate the patient.”

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

Supporting nonphysician personnel are also needed to work on ECMO/ECLS patients, depending upon the particular patient’s condition and the specific type of circuit. Nonphysician personnel includes ECMO/ECLS specialists, cardiac perfusionists, respiratory therapists, and specially trained nurses.

Coding rule: If the same physician provides any or all of the services for placing a patient on an ECMO/ECLS circuit, then he may report the appropriate codes for the service he performed, according to the 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.

Caution: 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.

“If different physicians provide parts of the service, each physician may report the correct code(s) for the service(s) they provided, except as noted,” per the guidelines.

Navigate Challenging ECMO/ECLS Documentation With These Helpful Tips

Harding offers the following tips she gives her surgeons to help your ECMO/ECLS reporting go more smoothly:

Tip 1: It is imperative to state why thecardio/respiratory and hemodynamic support is being established.

Tip 2: ECMO can be venovenous (VV) or venoarterial (VA), so it is essential to document this information.

Tip 3: If physician is performing ECMO on a neonate, he must document the patient’s age, weight, and gestational age.

Tip 4: If the physician is performing ECMO on an adult or child, it is important to be clear as to why ECMO is being used such as:

• Hypoxemic respiratory failure with a ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) of <100 mmHg despite optimization of the ventilator settings, including the tidal volume, positive end-expiratory pressure (PEEP), and inspiratory to expiratory (I:E) ratio
• Hypercapnic respiratory failure with an arterial pH less than 7.20
• Refractory cardiogenic shock
• Failure to wean from cardiopulmonary bypass after cardiac surgery
• As a bridge to either cardiac transplantation or placement of a ventricular assist device (VAD).

Tip 5: Some common studies to mention before and during ECMO support are as follows, according to Harding:

• Cardiac evaluation by ultrasound to rule out uncorrectable heart disease
• Head ultrasound (within 24 hours) to rule out significant (grade III and IV) intracranial hemorrhage
• Coagulation status tests, (e.g., partial thromboplastin »(PTT), prothrombin time (PT), fibrinogen, fibrin degradation products (FDP), platelet count)