Omar Hussain, D.O.
Clinical Assistant Professor, Loyola University Stritch School of Medicine
On January 1, 2015 Medicare deleted CPT codes 33960 (Prolonged extracorporeal circulation (ECMO) for cardiopulmonary insufficiency; initial day), 33961 (Prolonged extracorporeal circulation (EMCO) for cardiopulmonary insufficiency; each subsequent day), and 36822 (Insertion of Cannula(s) for Prolonged ECMO) and replaced these three codes with a new family of ECMO codes. These three codes were identified by CMS as potentially misvalued codes. CMS noted the services were originally valued when they were primarily provided to premature neonates. But the services are now typically used in treating adults with severe influenza, pneumonia, and the respiratory distress syndrome. For 2015, these codes will be replaced with 25 new codes to describe this treatment. The new codes will differentiate initiation vs continuation, patient age, veno-venous vs veno-arterial, insertion site, removal, and repositioning.
The ATS played an important role in the creation and valuation of the new family of CPT codes. The ATS worked closely with the AMA CPT committee, CMS, and sister organizations to ensure the new family of CPT codes accurately reflected the expanded use of ECMO in clinical care. The ATS also worked to ensure CMS adopted appropriate RUC values to ensure fair compensation for these procedures.
Adult and Pediatric Codes:
The following codes should be used for ECMO veno-venous and veno- arterial initiation and ECMO veno-venous and veno-arterial daily management for patients of any age. For patients requiring alternative insertion methods, repositioning, and removal, please see the adult and pediatric sections for the correct code.
33946 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; initiation, veno-arterial.
33948 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-venous.
33949 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; daily management, each day, veno-arterial.
Adult Codes
The following codes are used to describe the alternate insertion methods, repositioning, and removal of ECMO in patients 6-years old and older.
33952 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed).
33954 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older.
33956 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, 6 years and older.
33958 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed).
33962 Extracorporeal membrane oxygenation (ecmo ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed).
33964 Extracorporeal membrane oxygenation (ecmo ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed).
33966 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older.
33984 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older.
33986 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older.
ECMO Adult Vignette
A 60 year old with ARDS and persistent, severe hypoxemia, despite high levels of PEEP and appropriate salvage therapies, is considered for ECMO. His respiratory failure is potentially reversible. The patient also requires norepinephrine for hemodynamic support. Cardiovascular surgery places the veno-arterial cannulas percutaneously by Seldinger technique into the inferior vena cava and into the femoral artery. The MICU team manages the blood flow of the ECMO circuit on the first day. On the subsequent day, the MICU team continues to monitor venous oximetry and make adjustments.
Correct Coding:
Day 1: CV surgery bills 33952, MICU bills 33947
Day 2: MICU bills 33949
Please note, initiation codes (33946/33947) and daily management codes (33948, 33949) cannot be billed on the same day.
Pediatrics codes
The following codes are used to describe the alternative insertion methods, repositioning, and removal of ECMO in the pediatric population (<6 years old).
33951 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed).
33953 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age.
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.
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).
33959 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; reposition central (arterial and/or venous) cannula(e), open, birth through 5 years of age. (includes fluoroscopic guidance, when performed).
33963 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age. (includes fluoroscopic guidance, when performed).
33965 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age.
33969 Extracorporeal membrane oxygenation (ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age.
33985 Extracorporeal membrane oxygenation ( ECMO)/ extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age.
ECMO Pediatric Vignette
An infant with severe persistent pulmonary hypertension of the newborn remains hypoxic on maximal ventilator support despite inhaled nitric oxide. In order to maintain tissue oxygen delivery and avoid permanent lung injury, ECMO is considered. Pediatric surgery places the large catheters into the right jugular vein and into the right carotid artery. The NICU team manages the ECMO circuit on the first day and subsequent days.
Correct Coding:
Day 1: Surgery bills 33951, NICU bills 33947
Day 2: NICU bills 33949
Please note, initiation codes (33946/33947) and daily management codes (33948, 33949) cannot be billed on the same day.
Disclaimer
The information provided herein was current at the time of this communication. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. The opinions referenced are those of the members of the ATS Clinical Practice Committee and their consultants based on their coding experience. They are based on the commonly used codes in pulmonary, sleep and the critical care sections in CPT and HCPCS level II, which are not all inclusive. Always check with your local insurance carriers as policies vary by region. The final decision for the coding of a procedure must be made by the physician considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. The ATS and its representatives disclaim any liability arising from the use of these opinions. ®CPT is a registered trademark of the American Medical Association, CPT only copyright 2014 American Medical Association.
