Cardiovascular service lines across the country were taken by surprise last October, when CMS unveiled an unexpected and potentially paradigm-shifting change to coding and reimbursement for extracorporeal membrane oxygenation (ECMO). In its Inpatient Prospective Payment Systems (IPPS) final rule for fiscal year 2019, CMS announced that it would transition from classifying ECMO by a single ICD-10 procedure code to multiple codes. These codes would distinguish ECMO procedures by mode of vascular cannulation (central or peripheral) and indication (cardiac or respiratory), with different reimbursement for each code.
Coding changes for mode of cannulation
ECMO can be administered by two primary approaches: central and peripheral. Under the central approach, the ECMO device is connected directly to the heart, usually via the right atrium or the aorta. This method is highly invasive, requires a sternotomy, and is performed only for patients who are at imminent risk of death. The second approach, known as peripheral ECMO, connects the device to the body through the femoral artery, femoral vein, or internal jugular vein via a catheter. Peripheral ECMO is less invasive than its central counterpart and is used much more frequently.
The new ICD-10 procedure codes differentiate between central and peripheral cannulation. Previously, all ECMO procedures using the ICD-10 code 5A1223 were reimbursed through MS-DRG 003 at an average rate of $106,294 (for FY2018). Under the new ICD-10 codes, ECMO performed using a peripheral cannulation method can be reimbursed using MS-DRGs 291, 296, 207, 870, or 215, depending on disease state. ECMO performed centrally will continue to be reimbursed using MS-DRG 003.
The impact of these billing and coding changes is expected to be severe. Using historical procedure volume breakdowns provided in a letter to CMS from the Society of Thoracic Surgeons, our team modeled the potential financial impact on ECMO reimbursement. By applying these procedure ratios to the new coding requirements for ECMO, we expect that overall reimbursement may be as little as 30% of what was paid in FY2018. Because the data are retrospective, this model does not account for changes in coding practices that could increase the number of cases reimbursed using DRG 215 and result in a less severe reduction.
Changes facing pushback from the CV medical community
In changing the classification of ECMO, CMS attempted to link cost and complexity of ECMO care delivery to the method of cannulation. However, the decision has provoked significant criticism across systems, physician societies, and industry members. Many groups were taken aback by the lack of transparency with which the decision was made. These stakeholders maintain that cost and complexity of care provided to ECMO patients is unrelated to method of cannulation. Indeed, some argue that central cannulation is usually performed during CT surgery and that the costs of the sternotomy are rolled into different procedures altogether. Meanwhile, many systems fear that the reduction in reimbursement will be extremely harmful to ECMO programs and may make them financially unviable. It remains unclear whether CMS will stand firm on its decision in FY2020 or respond to criticisms with a full or partial return to the status quo.
Although the future of ECMO reimbursement is murky, adoption of ECMO as a staple of care for adult patients suffering from cardiac or respiratory failure is likely to continue to grow, particularly for systems with advanced heart failure offerings. In light of lower reimbursement, ECMO programs must commit to no-regrets strategies that will allow them to survive under conditions of change. Building an efficient staffing model, standardizing care protocols, and optimizing billing and coding procedures are essential to reduce unnecessary costs and ensure that no money is being left on the table.
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