5160-4-31 Coverage of extra -corporeal -membrane -oxygenator (ECMO) services.

(A) A physician may be reimbursed for the professional services associated with ECMO treatments for patients that meet the criteria for ECMO as set forth by the hospital where the service is performed. The hospital's criteria for ECMO must be consistent with acceptable medical practices .

(B) The department will not cover ECMO treatments performed for conditions for which the efficacy has not been established and the treatments have not been accepted as standard medical practice for the patient's condition. ECMO under these circumstances will be considered an experimental procedure. In general, ECMO is indicated for any cardiac and/or pulmonary condition (whether congenital or acquired) that is unresponsive to conventional therapy with a high likelihood of morbidity and/or mortality without ECMO.

(C) The physician who inserts the cannula for the ECMO procedure and initiates the ECMO treatment may be reimbursed for these services by billing current procedural terminology (CPT) code 36822. This procedure will be paid in addition to CPT code 33960 as noted in paragraph (I) of this rule.

(D) Reimbursement is available for professional services associated with the maintenance and management of ECMO treatments provided over a twenty-four-hour period.

(E) Except as provided for in paragraph (F) of this rule, reimbursement for evaluation and management services, including newborn critical care services, are bundled into the reimbursement for ECMO.

(F) Reimbursement is available for evaluation and management services, including newborn critical care services, provided prior to the initiation of ECMO treatments.

(G) Reimbursement is available for diagnostic, therapeutic, and surgical services that are not integral to ECMO treatment but are personally provided by the physician during the treatment .

(H) For the supervising physician to be entitled to reimbursement when residents, interns, or fellows are involved in the management of a patient during an ECMO treatment, the medical records must demonstrate that the supervising physician was personally present in the unit with sufficient regularity during the twenty-four hour period that it could be concluded that the supervising physician was personally responsible for the patient's care during the ECMO treatment.

(I) Providers should bill CPT code 33960 for the first twenty-four hours and 33961 for each additional twenty-four hours.

Regardless of the number of providers, no more than twenty-four hours of ECMO services shall be reimbursed during a twenty-four hour period.

Effective: 04/25/2011
R.C. 119.032 review dates: 01/12/2011 and 04/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02 , 5111.021
Prior Effective Dates: 5/25/91, 4/1/92 (Emer), 7/1/92, 3/31/94, 1/1/01