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Brief Communication

Update on Extracorporeal Membrane Oxygenation Coding

Fawley, Jason; Napolitano, Lena M.

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doi: 10.1097/MAT.0000000000000940
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Procedural coding for extracorporeal membrane oxygenation (ECMO) is changing in Fiscal Year 2019. All clinicians providing ECMO services for patients should be fully aware of the changes forthcoming and the potential impact on their coding and billing for ECMO.

New ECMO ICD-10-PCS Procedural Coding

The International Classification of Diseases, 10th Revision (ICD-10) Coordination and Maintenance Committee met in March 2018 and reviewed proposed changes to the ECMO ICD-10-PCS codes which were subsequently approved by the Centers for Medicare and Medicaid Services (CMS).1,2 Centers for Medicare and Medicaid Services released the fiscal year (FY) 2019 ICD-10, Procedure Coding System (ICD-10-PCS) changes on October 1, 2018.3 This includes 45 codes for “Extracorporeal or Systemic Assistance and Performance” and 46 codes for Extracorporeal or Systemic Therapies”.

In past years, ECMO coding was simple as there was only one code (ICD-10-PCS Procedure Code 5A15223) for ECMO. This ECMO code was initiated in January 1, 2015 during the first year of the nondraft ICD-10-PCS codes and was not changed thereafter. This code has now been deleted, with three (3) new ECMO codes established in 2018: one for central ECMO, one for peripheral veno-venous ECMO, and one for peripheral veno-arterial ECMO. This was based upon a belief that peripherally cannulated patients are less ill, the cannulation is less complex, and therefore the cost of caring for them will be less.

For discharges occurring October 1, 2018 and later, the FY 2019 ICD-10-PCS three (3) new ECMO codes must be used. The key to selecting the correct code is based on the method of ECMO cannulation (central vs. peripheral) and type of ECMO (veno-venous vs. veno-arterial). The three new codes for ECMO are as follows:

  1. 5A1522F - Extracorporeal Oxygenation, Membrane, Central
  2. 5A1522G - Extracorporeal Oxygenation, Membrane, Peripheral Veno-arterial
  3. 5A1522H - Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous

There is significant concern regarding whether coders will be able to determine the type of ECMO that is performed to allow correct procedural coding, and physicians may need to assist.

New ECMO ICD-10-PCS Procedure Codes and Diagnosis-Related Groups

The prior ECMO Medicare Severity Diagnosis-Related Group (Medicare Severity Diagnosis-Related Group [MS-DRG] 003, ECMO, or Tracheostomy with Mechanical Ventilation greater than 96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure)4 was used with the prior ICD-10-PCS Procedure Code 5A15223 for ECMO.

Clinical advisors to CMS supported the designation of the peripheral ECMO procedures as a non-Operating Room procedure and therefore were assigned to a different Diagnosis-Related Group (DRG) for billing. They recommended that “any patient with a respiratory diagnosis who requires treatment involving a peripheral ECMO procedure should be assigned to MS-DRG 207 (page 25 of Federal Register, Vol. 83, No 160, Friday, August 17, 2018).”5 Similarly, MS-DRG assignments were changed for other percutaneous ECMO procedures for heart failure, shock, cardiac arrest, and sepsis.

Effective October 1, 2018, the two new ICD-10-PCS Procedure Codes describing percutaneous (peripheral) ECMO procedures (5A1522G and 5A1522H) are designated as non-Operating Room procedures with the following MS-DRG assignments:

  • MS–DRG 207 Respiratory System Diagnosis with Ventilator Support greater than 96 Hours or Peripheral ECMO.
  • MS–DRG 291 Heart Failure and Shock with major complication or comorbidity (MCC) or Peripheral ECMO.
  • MS–DRG 296 Cardiac Arrest, Unexplained with MCC or Peripheral ECMO.
  • MS–DRG 870 Septicemia or Severe Sepsis with MV greater than 96 Hours or Peripheral ECMO.

The MS–DRG assignment for the central ECMO procedures (ICD-10-PCS Procedure Code 5A1522F) remains in MS–DRG 003.

Data from the National Summary of Inpatient Charge Data by MS-DRG6 confirmed significant differences regarding DRG use and charges/payments and particular differences related to mean hospital length of stay (Table 1).7 Centers for Medicare and Medicaid Services also clarified the following: “In cases where a percutaneous external heart assist device is utilized, in combination with a percutaneous ECMO procedure, effective October 1, 2018, the ICD-10 MS-DRG Version 36 GROUPER logic results in a case assignment to MS-DRG 215 because the percutaneous external heart assist device procedure is designated as an Operating Room procedure and assigned to MS-DRG 215.”

Table 1
Table 1:
Differences in New MS-DRG Codes Assigned for Percutaneous ECMO

Although these changes apply only to CMS beneficiaries at present, which represent less than 10% of all adult ECMO cases, it is expected that private insurance will mirror these codes in the future. Significant concern has been expressed by the ECMO community regarding these changes in ECMO coding and reimbursement, and the Extracorporeal Life Support Organization (ELSO) is taking the lead on further negotiation of these issues with CMS.8 ELSO has partnered with the Society of Thoracic Surgeons (STS) in responding to CMS with data from the ELSO registry, and large clinical sites demonstrating that peripherally cannulated patients are NOT less ill and the cost of caring for them is also NOT lower than centrally cannulated ECMO patients. Extracorporeal Life Support Organization and STS are building a coalition of many other professional societies in their response to CMS, hoping to reverse this decision.

ECMO ICD-10-CM Diagnosis Coding

The ICD-10 Coordination and Maintenance Committee reviewed a total of 26 diagnosis codes which were put forward for consideration for FY 2019. Centers for Medicare and Medicaid Services released the FY 2019 ICD-10, Clinical Modification (ICD-10-CM), but no changes to ECMO diagnosis codes were made.9 The ICD-10-CM Diagnosis Code Z92.81 is defined as “Personal history of ECMO”. This code was initiated as a new code effective January 1, 2015 and has not been changed since that time.

ECMO CPT Codes

In January 2015, the following three (3) ECMO Current Procedural Terminology (CPT) codes were deleted:

  • 33960: Prolonged ECMO for cardiopulmonary insufficiency; initial day
  • 33961: Prolonged ECMO for cardiopulmonary insufficiency; each subsequent day
  • 36822: Insertion of Cannula(s) for Prolonged ECMO

These three ECMO codes were replaced by 25 new codes to describe ECMO management and specifically to differentiate ECMO initiation vs. continuation, patient age, ECMO type (veno-venous vs. veno-arterial), ECMO cannula insertion, and ECMO cannula removal and repositioning (Tables 2 and 3). These changes in ECMO CPT codes increased the work relative value units (RVUs) of insertion, reposition and removal of ECMO cannulae, and separated out and decreased the RVUs for the daily management.10 Each code has a 0-day global period. Although physician work RVUs have been stable 2016–2018, total facility RVUs and payment have decreased during that time period for many of the ECMO codes.

It is strongly recommended that separate procedure/operative notes be completed for ECMO cannula insertion, reposition, or removal to support these CPT codes. Critical care time (CPT code 99291, first 74 minutes; 99292, each additional 30 minutes of critical care) can also be billed in addition to ECMO for services provided to the patient other than ECMO and exclusive of the time spent during invasive diagnostic or therapeutic procedures with appropriate critical care documentation.

Table 2
Table 2:
ECMO Initial Cannulation and Initiation/Daily Management Codes
Table 3
Table 3:
Adult and Pediatric ECMO Cannula Reposition and Removal Codes

References

1. Johnson L; C&M Meeting, Part I: The Latest Update on Procedure Code Proposals. ICD10 Monitor. Updated March 26, 2018. Available at: https://www.icd10monitor.com/c-m-meeting-part-i-the-latest-update-on-procedure-code-proposals. Accessed October 29, 2018.
2. Scott N; Coding Corner: A look at the proposed 2019 ICD-10 Codes. For the Record Vol. 30, No. 6, Pg 6. June/July 2018. Available at: https://www.fortherecordmag.com/archives/JJ18p8.shtml. Accessed October 29, 2018.
3. 2019 ICD-10 PCS. Available at: https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html. Accessed October 29, 2018.
4. Draft ICD-10-CM/PCS MS-DRGv28 definitions manual. Available at: https://www.cms.gov/icd10manual/fullcode_cms/P0040.html. Accessed October 29, 2018.
5. Federal Register / Vol. 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations: 41166-41169. Available at: https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf. Accessed October 29, 2018.
6. National Summary of Inpatient Charge Data by Medicare Severity Diagnosis Related Group. Data.CMS.gov. Available at: https://data.cms.gov/Medicare-Inpatient/National-Summary-of-Inpatient-Charge-Data-by-Medic/efwk-h4x3/data. Accessed October 29, 2018.
7. FY 2019 final rule and correction notice tables. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page-Items/FY2019-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending. Accessed October 29, 2018.
8. Extracorporeal life support organization center for medicare services (CMS) - reimbursement for ECMO. Available at: https://www.elso.org/Portals/0/CMS%20Changes%20in%20ECMO%20reimbursements%20-%20ELSO%20Report.pdf. Accessed October 29, 2018.
9. 2019 ICD-10-CM Code Updates to start October 1, 2018. Available at: https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html. Accessed October 29, 2018.
10. Blum JM, Lynch WR, Coopersmith CM. Clinical and billing review of extracorporeal membrane oxygenation. Chest 2015.147: 1697–1703
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