ECMO Coding Changes Karen Bridgeman, MSN, RN, CCDS CDI Educator Medical University of South Carolina

Karen Bridgeman, MSN, RN, CCDS has been a Clinical Documentation Specialist for over ten years, and is the CDI Educator for the Medical University of South Carolina. In 2012, she developed and implemented the successful Pediatric CDI Program at the Medical University of South Carolina’s Children’s Hospital. She is a frequent contributor on pediatric subject matter for the ACDIS Journal and has presented at several ACDIS National Conferences. In addition, she is the author of the CDI Essential Skills Online Learning Library. She currently serves on ACDIS’s CCDS Certification Board.

What Is ECMO Extracorporeal Membrane Oxygenation (ECMO) Extracorporeal means outside the body A membrane oxygenator is a piece of equipment which acts as a lung to deliver oxygen into the child’s blood The ECMO circuit acts as an artificial heart and lung for the patient during ECMO therapy Pumps and oxygenate the blood outside the body, allowing the heart and lungs to rest https://www.maxhealthcare.in/top-procedures/ecmo

ECMO Circuit Jürgen Schaub. de:User:Mr.Flintstone [CC BY-SA 2.0 de (https://creativecommons.org/licenses/by-sa/2.0/de/deed.en)], from Wikimedia Commons

Central Cannulation Central cannulation is an open chest procedure or via thoracotomy or sternotomy More common in infants with congenital heart defects Central ECMO most commonly occurs in patients who are already in the operating room with their chest already open Most commonly in patients when the heart has not recovered enough near the end of a cardiac surgical procedure and patient can not come off cardiopulmonary bypass Copyrighted material used with permission of the author, University of Iowa Hospitals & Clinics, uihc.org.

Peripheral Cannulation Insertion of cannula via femoral, cervical, or axillary vessels Percutaneously or open surgical cutdown Neonates most often cannulated through the neck Although the peripheral cannulation method is different from central cannulation, the risks for both patients remain the same Resources utilization is the same regardless of peripheral or central cannulation It is the high acuity of illness and complexity of ECMO support that drives the cost of care Mr.Flintstone [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)]

Veno-arterial (VA) ECMO Cardiac or Respiratory Failure Veno-venous (VV) ECMO Isolated Respiratory Failure Van Meurs, K, Lally, KP, Peek, G, Zwischenberger, Extracorporeal Life Support Organization, Ann Arbor 2005. [CC BY 2.5 (https://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

ICD-10-PCS Codes ICD-10-PCS Code Title 5A1522F Extracorporeal Oxygenation, Membrane, Central 5A1522G Extracorporeal Oxygenation, Membrane, Peripheral Veno-arterial 5A1522H Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous The ICD-10-PCS code set moved from a single code for ECMO to three separate PCS codes differentiated by the mode of vascular access or cannulation. Peripheral cannulation is not regarded as a surgical procedure. Peripheral cannulation greatly impacts reimbursement.

MS-DRG Grouper for ECMO MDC MS-DRG MS-DRG Title Weight GLOS ALOS PRE 003 ECMO or Trach w MV >96 HRS or PDX Exc Face, Mouth & Neck w Maj O.R. 18.2974 23.4 30.1 207 Respiratory System Diagnosis w Ventilator Support >96 HRS or Peripheral Extracorporeal Membrane Oxygenation (ECMO) 5.5965 12.0 13.9 05 291 Heart Failure & Shock w MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO) 1.3454 4.1 5.2 296 Cardiac Arrest, unexplained w MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO) 1.5355 2.0 3.2 18 870 Septicemia or Severe Sepsis w MV >96 HRS or Peripheral Extracorporeal Membrane Oxygenation (ECMO) 6.2953 12.4 14.4

Coding Clinic Percutaneous extracorporeal membrane oxygenation ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2018 Pages: 52-54 Effective with discharges: October 1, 2018 There are three types of ECMO that correspond to the new ICD-10-PCS qualifiers: Central, Venous-Arterial (VA) Peripheral and Venous-Venous (VV) Peripheral. Central ECMO cannulation is an open-chest procedure with direct surgical cannulation of the right atrium and aorta. It involves two open insertions, arterial and venous, and provides cardiorespiratory support. In the past, central ECMO was more commonly used; however, peripheral ECMO is more common now. For central ECMO, assign code 5A1522F, Extracorporeal oxygenation, membrane, central. VA peripheral ECMO cannulation involves two femoral percutaneous insertions: arterial and venous. The VA ECMO is used when there are problems with both the heart and lungs. This type of ECMO provides respiratory and circulatory support. Code 5A1522G, Extracorporeal oxygenation, membrane, peripheral veno-arterial, is used for VA peripheral ECMO. VV ECMO involves two venous insertions, one in the upper veins and one in the lower veins. It is used when the problem is only in the lungs. Code 5A1522H, Extracorporeal oxygenation, membrane, peripheral veno-venous, is used for VV peripheral ECMO.

APR-DRG Grouper for ECMO Title Weight ALOS 004-1 Tracheostomy w MV 96 HRS w Ext Procedure or ECMO 5.0795 12.07 004-2 6.9107 20.01 004-3 10.0250 25.83 004-4 Tracheostomy w MV 95 HRS w Ext Procedure or ECMO 14.4234 37.75 APR-DRG Title Weight ALOS 583-1 Neonate w ECMO 8.2379 22.50 583-2 9.1532 25.00 583-3 17.1604 35.90 583-4 25.6605 64.84

APR-DRG v35.0 Modification Title Weight ALOS 009-1 Extracorporeal membrane oxygenation (ECMO) 5.5141 7.00 009-2 7.5019 6.71 009-3 10.8826 13.95 009-4 15.3660 29.91 Revised APR-DRG 004 Tracheostomy w MV 96 HRS w Extensive Procedure Neonates 15+ days of life

Neonatal ECMO APR-DRG v35.0 vs. MS-DRG Neonates 0 – 14 days of life on admission DRG Grouper Central Cannulation Peripheral Cannulation APR-DRG APR-DRG 583 Neonate w ECMO MS-DRG MS-DRG 003 ECMO or Trach w MV >96 HRS or PDX Exc Face, Mouth, & Neck w Maj O.R. MS-DRG 789-794 Dependent upon appropriate neonatal MS-DRG assignment Neonates 15+ days of life on admission DRG Grouper Central Cannulation Peripheral Cannulation APR-DRG APR-DRG 009 ECMO Dependent upon principal diagnosis & DRG assignment MS-DRG MS-DRG 003 ECMO or Trach w MV >96 HRS or PDX Exc Face, Mouth, & Neck w Maj O.R. MS-DRG 789-794 Dependent upon appropriate neonatal MS-DRG assignment

Pediatric ECMO APR-DRG v35.0 vs. MS-DRG DRG Grouper Central Cannulation Peripheral Cannulation* APR-DRG APR-DRG 009 ECMO APR-DRG 133 Respiratory Failure MS-DRG MS-DRG 003 ECMO or Trach w Vent >96 HRS or PDX EXC Face, Mouth & Neck w Maj O.R. MS-DRG 207 Respiratory System Diagnosis w Ventilator Support >96 HRS or Peripheral Extracorporeal Membrane Oxygenation (ECMO) *The DRG grouping for ECMO with peripheral cannulation will be dependent upon the principal diagnosis and DRG assignment For this example, the principal diagnosis would be acute respiratory failure.

Neonatal ECMO APR-DRG v32.0 vs. MS-DRG Neonates 0 – 14 days of life on admission DRG Grouper Central Cannulation Peripheral Cannulation APR-DRG APR-DRG 583 Neonate w ECMO MS-DRG MS-DRG 003 ECMO or Trach w MV >96 HRS or PDX Exc Face, Mouth, & Neck w Maj O.R. MS-DRG 789-794 Dependent upon appropriate neonatal MS-DRG assignment Neonates 15+ days of life on admission DRG Grouper Central Cannulation Peripheral Cannulation APR-DRG APR-DRG 004 Trach w MV 96+ HRS w Ext Procedure or ECMO APR DRG 004 Trach w MV 96+ w Ext Procedure or ECMO MS-DRG MS-DRG 003 ECMO or Trach w MV >96 HRS or PDX Exc Face, Mouth, & Neck w Maj O.R. MS-DRG 789-794 Dependent upon appropriate neonatal MS-DRG assignment

Pediatric ECMO APR-DRG v32.0 vs. MS-DRG DRG Grouper Central Cannulation Peripheral Cannulation APR-DRG APR-DRG 004 Trach w MV 96+ HRS w Ext Procedure or ECMO MS-DRG MS-DRG 003 ECMO or Trach w Vent >96 HRS or PDX EXC Face, Mouth & Neck w Maj O.R. MS-DRG 207 Respiratory System Diagnosis w Ventilator Support >96 HRS or Peripheral Extracorporeal Membrane Oxygenation (ECMO) For this example, the principal diagnosis would be acute respiratory failure.

Transfer in on ECMO There is not an ICD-10-CM/PCS code to assign for the presence of ECMO on admission When critically ill patients are transferred, the receiving hospital does not receive any compensation for the continuation of ECMO therapy. Recommend to use code: Z95.811 Presence of heart assist device This is a complication and co-morbidity (CC) With a severity of illness (SOI) level 3 and risk of mortality (ROM) level 4 Since these critically ill patients will most likely have multiple CCs and/or MCCs, this in all likelihood will not impact the MS-DRG assignment Will not fall into one of the five MS-DRG groupings for ECMO as cannulation occurred at the outside facility.

Tracking ECMO Patients

Any Questions? Karen Bridgeman, MSN, RN, CCDS bridgema@musc.edu