Cardiology Coding Alert

Hint: You must know if the ECMO was veno-arterial or veno-venous.

When it comes to reporting extracorporeal membrane oxygenation (ECMO) procedures in your cardiology practice, you must check the medical documentation for numerous details including what kind of ECMO your cardiologist performed, what kind of management they performed, and which services may bundle together.

Editor’s note: You may also see the term “extracorporeal life support (ECLS)” in your physician’s medical documentation. ECLS is the same as ECMO. This procedure allows a compromised heart and/or lungs to rest by providing blood oxygenation and carbon dioxide clearance outside of the body. The patient’s blood is removed, treated, and returned to the body via cannula(e), or thin tube(s).

Read on to learn more.

Myth 1: Only 1 ECMO Method Exists

Reality: Your physician can use two methods to accomplish ECMO.

Method 1: The first method of ECMO is veno-arterial (VA). This procedure 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.

Method 2: The second method of ECMO is veno-venous (VV). VV ECMO takes blood from a vein and returns it to a vein. VV EMCO supports lung function only and requires one or two cannula(e), which your physician will place in a vein.

Remember: “It’s important to make sure documentation for ECMO cannulation provides what type of ECMO the patient is receiving, where and how the cannula was placed, and the age of the patient,” says Robin Peterson, CPC, CPMA, Manager of Professional Coding, Pinnacle Integrated Coding Solutions, LLC. “Make sure to query the provider if these details are missing.”

Myth 2: You Can’t Separately Report ECMO Initiation

Reality: CPT^® gives you the following two codes to report initial cannulation and repositioning, removing, or adding of cannula(e) while the ECMO is supporting the patient:

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

Remember: 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, per CPT^®.

“Initiation of ECMO documentation should include the necessary device components, blood flow, gas exchange and other necessary parameters, while daily management documentation should include management of blood flow, oxygenation, CO2 clearance by the membrane lung, systemic response, anticoagulation, and treatment of bleeding, cannula positioning, alarms, and safety,” Peterson explains.

Myth 3: Daily ECMO Management Codes Same as Daily Overall Management Codes

Reality: You should report different codes for the daily patient’s ECMO management versus the patient’s daily overall management.

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

Codes 33948 and 33949: The daily management of the ECMO circuit and monitoring parameters, codes 33948 and 33949, requires your physician’s oversight to make sure 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.

On the other hand, you may separately report the daily overall management of the patient with the appropriate hospital observation codes, hospital inpatient services, or critical care evaluation and management (E/M) codes.

Some of these applicable E/M codes include but are not limited to the following:

• 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity…)-99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity…)
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity…)-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity…)
• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)-+99292 (… each additional 30 minutes (List separately in addition to code for primary service))

Caution: When considering the daily overall management of the patient, you must look for details in the documentation such as the patient’s age, the disease process, and the condition.

Myth 4: Multiple Physicians Cannot Be Involved During ECMO

Reality: Multiple physicians and supporting nonphysician personnel will usually be involved during ECMO procedures, per the CPT^® guidelines.

“Different physicians may insert the cannula(e) and initiate ECMO, manage the ECMO circuit, and decannulate the patient,” according to the guidelines.

When multiple physicians are involved in ECMO, 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 typically of different specialties, and significant physician team interaction is usually necessary.

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

Rule: If the same physician provides any or all of the services for placing a patient on an ECMO circuit, then he may report the appropriate codes for the service he performed, according to the guidelines. These codes can include 33951-33956 for the cannula(e) insertion, 33946 or 33947 for the ECMO initiation, and the appropriate E/M code for overall patient management.

Caution: The same or different individuals may not report 33948 or 33949 for ECMO 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,” according to the guidelines.

Myth 5: No ECMO Services Are Bundled

Reality: CPT^® identifies specific circumstances where ECMO procedures are bundled, so you can’t report these services separately.

Take a look at some situations you may encounter when your physician performs ECMO with other services.

Insert/reposition: During the session that your physician reports a cannula placement code (33951-33956), you should not additionally report a cannula reposition code (33957-33964), even if the surgeon changes the cannula placement during that session.

Initiate/reposition: Although you would expect to report a cannula insertion code on ECMO initiation day, CPT^® instruction says that you should not report a cannula reposition code (33957-33964) on the same day as the ECMO initiation (33946-33947).

Fluoroscopic guidance/reposition: If your physician uses fluoroscopic guidance during a cannula repositioning service (33957-33964), you should not separately report the imaging service, because it is included.

Replacement restrictions: If your physician removes a cannula from a vessel and replaces it with a cannula in the same vessel, you can’t report the service using both a removal and an insertion code, according to CPT^®. Instead, you should report the replacement using just the appropriate insertion code from the range 33951-33956.

On the other hand, if the physician removes a cannula from one vessel and places a new cannula in a different vessel, you can report both a removal code (33965-33986) and an insertion code (33951-33956).