Chest
Volume 134, Issue 1, July 2008, Pages 179-184
Journal home page for Chest

Topics in Practice Management
Extracorporeal Membrane Oxygenation*: Current Clinical Practice, Coding, and Reimbursement

https://doi.org/10.1378/chest.07-2512Get rights and content

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Section snippets

Neonatal Respiratory Failure

Bartlett and colleagues4 reported the first case series of 28 patients (14 children, 14 adults) who were treated with ECMO in 1977. Although only 5 of 28 patients were long-term survivors, the early successes in near-moribund patients led to the first randomized trials of ECMO therapy for respiratory failure in neonates. The first of these trials used a nontraditional “play-the-winner” randomization technique, where the chance of assigning an infant to a treatment was influenced by the outcome

Respiratory Failure

Today, most current controversy surrounds the use of ECMO in adult patients with respiratory failure. The first randomized trial20 comparing patients in nine medical centers treated with ECMO or conventional ventilation was published in 1979. The survival rate in both groups was < 10%, and no significant difference in mortality was observed between patients receiving ECMO or conventional ventilation. ECMO proponents today point out that this study was performed in the early days of the field,

Emergent ECMO (Extracorporeal Cardiopulmonary Resuscitation)

ECMO has recently been used29 as a last means of resuscitation for patients undergoing CPR. Extracorporeal cardiopulmonary resuscitation has recently been demonstrated30 to be associated with survival rates to hospital discharge of 34 to 38% in pediatric patients. Similar results have been seen in adult patients among whom survival rates of 38% have been reported.14 Although survival rates in patients undergoing extracorporeal cardiopulmonary resuscitation are not as high as for other ECMO

Bedside Management

ECMO is an intensive therapy with a learning curve in its application,22 and its practice is best suited to centers where the expertise exists in daily management. For this reason, regionalization is appropriate to ensure that adequate volumes are present at each ECMO center. Given the acuity of care and the risk of sudden decompensation if the circuit fails, special training is mandatory for physicians, nurses, respiratory therapists, and patient care technicians providing care to ECMO

Coding and Documentation

Current procedural terminology (CPT) codes31 and relative value units32 for ECMO cannulation and management are listed in Table 2. Charge and reimbursement for ECMO services will vary based on provider and payer, respectively. CPT code 36822 covers ECMO cannulation. This code is the same regardless of whether cannulation occurs via the VA or VV approach and regardless of whether the vasculature is cannulated through the chest, neck, or groin. The code also makes no distinction between open and

Conclusion

ECMO is currently being used in ICUs worldwide for neonatal, pediatric, and adult respiratory and cardiac failure. Evidence to support its use is strongest in the neonatal population, but treatment in the pediatric population is also generally accepted. The usage of ECMO in cases of adult respiratory failure is currently controversial, although the promising results of the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (or CESAR) trial (which await publication in the

Acknowledgment

We thank the Office of Physician Billing Compliance for helpful suggestions and for critical review of this manuscript.

References (35)

  • PP O'Rourke et al.

    Extracorporeal membrane oxygenation and conventional medical therapy in neonates with persistent pulmonary hypertension of the newborn: a prospective randomized study

    Pediatrics

    (1989)
  • UK Collaborative ECMO Trail Group

    UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation

    Lancet

    (1996)
  • CJ Shanley et al.

    Extracorporeal life support for neonatal respiratory failure: a 20-year experience

    Ann Surg

    (1994)
  • KW West et al.

    Delayed surgical repair and ECMO improves survival in congenital diaphragmatic hernia

    Ann Surg

    (1992)
  • S Petrou et al.

    Cost-effectiveness of neonatal extracorporeal membrane oxygenation based on 7-year results from the United Kingdom Collaborative ECMO Trial

    Pediatrics

    (2006)
  • M Keszler et al.

    Multicenter controlled clinical trial of high-frequency jet ventilation in preterm infants with uncomplicated respiratory distress syndrome

    Pediatrics

    (1997)
  • GM Hoffman et al.

    Inhaled nitric oxide reduces the utilization of extracorporeal membrane oxygenation in persistent pulmonary hypertension of the newborn

    Crit Care Med

    (1997)
  • Cited by (79)

    • The Atrial Flow Regulator: A Novel Device for Left Ventricular Unloading in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support?

      2021, Chest
      Citation Excerpt :

      Urgent heart transplantation was now unlikely, and therefore the patient benefited from a biventricular assistance device (Berlin Heart) combined with extraction of the AFR device, 6 days after the procedure (Fig 1F). VA ECMO is the preferred mechanical support for patients in cardiogenic shock with biventricular failure, allowing tissue perfusion as a bridge to recovery with long-term mechanical circulatory support, or transplantation.3-5 However, retrograde flow from the femoral artery can induce increased afterload, left ventricular distension, and severe pulmonary edema.

    • Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis

      2020, Resuscitation Plus
      Citation Excerpt :

      Extracorporeal cardiopulmonary resuscitation (ECPR), or cardiopulmonary resuscitation (CPR), assisted by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a method of temporary mechanical circulatory support based on utilization of an extracorporeal membrane oxygenation (ECMO) system.1–3

    • Respiratory Support and Artificial Ventilation

      2016, Nunn's Applied Respiratory Physiology
    • Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians

      2015, Journal of Emergency Medicine
      Citation Excerpt :

      This success was attributed to the fact that in neonatal respiratory failure, the lungs require only a short time for recovery (9). Subsequently, ECMO has been used in NICUs for the treatment of respiratory failure due to primary pulmonary hypertension of the newborn, meconium aspiration syndrome, persistent fetal circulation, and congenital diaphragmatic hernia, yielding survival rates of >80% (10). From the success in neonates, and supported by good evidence-based medicine for treatment of respiratory failure, the technology was adapted to pediatrics in the early 1980s.

    View all citing articles on Scopus

    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text