ECMO Coding Changes Karen Bridgeman, MSN, RN, CCDS - PowerPoint Presentation

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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 bodyA membrane oxygenator is a piece of equipment which acts as a lung to deliver oxygen into the child’s bloodThe ECMO circuit acts as an artificial heart and lung for the patient during ECMO therapyPumps 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 openMost 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

Mr.Flintstone [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)]

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

Veno

-arterial (VA) ECMO

Cardiac or Respiratory Failure

Veno-venous (VV) ECMOIsolated 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 CodeTitle5A1522FExtracorporeal Oxygenation, Membrane, Central5A1522GExtracorporeal Oxygenation, Membrane, Peripheral Veno-arterial5A1522HExtracorporeal 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

PRE

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

05

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

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. 

Percutaneous extracorporeal membrane oxygenation

ICD-10-CM/PCS Coding Clinic,

Fourth Quarter ICD-10 2018

Pages: 52-54 Effective with discharges: October 1, 2018

APR-DRG Grouper for ECMO

APR-DRGTitleWeightALOS004-1Tracheostomy w MV 96 HRS w Ext Procedure or ECMO5.079512.07004-2Tracheostomy w MV 96 HRS w Ext Procedure or ECMO6.910720.01004-3Tracheostomy w MV 96 HRS w Ext Procedure or ECMO10.025025.83004-4Tracheostomy w MV 95 HRS w Ext Procedure or ECMO14.423437.75

APR-DRG

Title

Weight

ALOS

583-1

Neonate w ECMO

8.2379

22.50

583-2

Neonate w ECMO

9.1532

25.00

583-3

Neonate w ECMO

17.1604

35.90

583-4

Neonate w ECMO

25.6605

64.84

APR-DRG v35.0 Modification

APR-DRGTitleWeightALOS009-1Extracorporeal membrane oxygenation (ECMO)5.51417.00009-2Extracorporeal membrane oxygenation (ECMO)7.50196.71009-3Extracorporeal membrane oxygenation (ECMO)10.882613.95009-4Extracorporeal membrane oxygenation (ECMO)15.366029.91

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 GrouperCentral CannulationPeripheral CannulationAPR-DRGAPR-DRG 583 Neonate w ECMOAPR-DRG 583 Neonate w ECMOMS-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 GrouperCentral CannulationPeripheral Cannulation*APR-DRGAPR-DRG 009 ECMOAPR-DRG 133 Respiratory FailureMS-DRGMS-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 GrouperCentral CannulationPeripheral CannulationAPR-DRGAPR-DRG 583 Neonate w ECMOAPR-DRG 583 Neonate w ECMOMS-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 GrouperCentral CannulationPeripheral CannulationAPR-DRG APR-DRG 004 Trach w MV 96+ HRS w Ext Procedure or ECMOAPR-DRG 004 Trach w MV 96+ HRS w Ext Procedure or ECMO MS-DRGMS-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