Coding Tip of the Month – September 2018

New ECMO Procedural Codes

Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life. The technology for ECMO is largely derived from cardiopulmonary bypass, which provides shorter-term support.

This intervention has mostly been used on children, but it is seeing more use in adults with cardiac and respiratory failure. ECMO works by removing blood from the body and artificially removing the carbon dioxide and oxygenating red blood cells. Generally, it is used either post-cardiopulmonary bypass or in late stage treatment of a person with profound heart and/or lung failure awaiting transplants, although it is now seeing use as a treatment for cardiac arrest in certain centers, allowing treatment of the underlying cause of arrest while circulation and oxygenation are supported.

These new and the revised ECMO procedure code and description, effective October 1^st, 2018, are shown in the following table.

PCS Code	Code Description	Clinical Description
5A1522F	Extracorporeal Oxygenation, Membrane, Central	Requires a sternotomy with direct surgical cannulation of the right atrium and the ascending aorta. The advantage of this technique is that it can provide the best perfusion flow and offload the left ventricle A major disadvantage is that it bypasses the lungs and heart creating a significant risk of thrombosis Provides both respiratory and circulatory support.
5A1522G	Extracorporeal Oxygenation, Membrane, Peripheral Veno-arterial	In veno-arterial (VA) ECMO, a venous cannula is usually placed in the right or left common femoral vein or IVC for extraction, and an arterial cannula is usually placed into the right or left femoral artery for adult infusion or common carotid for neonates. Indications for VA-ECMO include: refractory cardiogenic shock, failure to wean from cardiopulmonary bypass, fulminant myocarditis, decompensated chronic heart failure, peripartum cardiomyopathy and as a pre-operative or postoperative bridge to durable LVAD or heart and lung transplants.
5A1522H	Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous	In veno-venous (VV) ECMO, cannulae are usually placed in the right common femoral vein for drainage and right internal jugular vein for infusion. Alternatively, a dual-lumen catheter is inserted into the right internal jugular vein, draining blood from the superior and inferior vena cava and returning it to the right atrium. Indications for VV-ECMO include: hypoxic respiratory failure, deteriorating patient on a lung transplantation list, immediate respiratory collapse (asphyxia, pulmonary embolism), and bridge for patients awaiting lung transplant. This technique provides only respiratory support and therefore relies on the patient’s own circulation and requires adequate cardiac function.

The MS-DRG assignment for a central ECMO procedure (5A1522F) will remain in Pre-MDC MS-DRG 003.

Effective October 1^st, 2018, the MS-DRGs for the percutaneous ECMO procedures (5A1522G and 5A1522H) which are non-OR procedures will affect MS-DRG assignment as shown in the following table, along with the revised MS-DRG titles.

MDC	MS-DRG	MS-DRG Title
4	207	Respiratory System Diagnosis with Ventilator Support >96 Hours or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
5	291	Heart Failure and Shock with MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
5	296	Cardiac Arrest, Unexplained with MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
18	870	Septicemia or Severe Sepsis with MV>96 Hours or Peripheral Extracorporeal Membrane Oxygenation (ECMO)