CPT® Code 33964

Official Description

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed)

Common Language Description

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) are terms that refer to advanced medical procedures designed to provide long-term support for patients experiencing severe heart and lung failure. These procedures involve the use of a sophisticated system that circulates blood outside the body through an artificial lung, which oxygenates the blood and removes carbon dioxide before returning it to the patient's bloodstream. The process is critical for patients who cannot maintain adequate oxygenation or perfusion due to various medical conditions. The repositioning of central cannula(e) is a specific procedure performed under this umbrella of support, particularly when the initial placement of the cannula(e) requires adjustment to ensure optimal function. This repositioning is typically necessary when the cannula(e) have been placed in the right atrial appendage and the aortic arch or ascending aorta, or in cases of primary left heart failure where the left atrium has been cannulated to relieve pressure. The procedure is performed through a transthoracic approach, which may involve either a sternotomy (opening the chest through the sternum) or a thoracotomy (opening the chest through the ribs). Fluoroscopic guidance may be utilized during the procedure to ensure accurate placement of the cannula(e). This code, CPT® 33964, specifically applies to patients aged 6 years and older, distinguishing it from code 33963, which is used for younger patients (newborn through 5 years of age).

1. Indications

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) procedures are indicated for patients experiencing severe cardiac and respiratory failure. The specific indications for the repositioning of central cannula(e) include:

Severe Heart Failure: Patients with significant left heart failure may require left atrial cannulation to facilitate decompression and improve hemodynamics.
Right Atrial Cannulation: When the right atrial appendage is cannulated, repositioning may be necessary to optimize blood flow and support.
Aortic Arch/Ascending Aorta Cannulation: In cases where cannulation of these structures has occurred, repositioning ensures proper placement for effective support.

2. Procedure

The procedure for repositioning central cannula(e) in patients aged 6 years and older involves several critical steps:

Step 1: Preparation and Anesthesia The patient is prepared for the procedure, which includes administering appropriate anesthesia to ensure comfort and safety during the intervention.
Step 2: Incision A standard vertical sternotomy incision is made through the sternum or a thoracotomy approach is utilized to access the thoracic cavity. This allows the physician to visualize and access the cannula(e) and associated vessels directly.
Step 3: Identification of Cannula(e) Once the chest is opened, the physician identifies the central cannula(e) and the vessels into which they are placed. This step is crucial for ensuring that the repositioning can be performed accurately.
Step 4: Fluoroscopic Guidance Fluoroscopy may be employed to provide real-time imaging, assisting the physician in confirming the position of the cannula(e) as they are manipulated.
Step 5: Repositioning of Cannula(e) The cannula(e) are repositioned within the vessel(s) using gentle manual pressure or a snare technique. This adjustment is made to ensure optimal placement for effective blood flow and oxygenation.
Step 6: Securing the Cannula(e) Once the optimal position is confirmed, the cannula(e) are secured in place using sutures to prevent movement and ensure stability.
Step 7: Closure of Incision The incision is then closed in layers, ensuring proper healing and minimizing the risk of complications.
Step 8: Reconnection of ECMO/ECLS Circuit After the incision is closed, the ECMO/ECLS circuit is reconnected, and the tubing is secured to the skin using sutures and/or dressings to maintain stability and prevent dislodgement.

3. Post-Procedure

Post-procedure care involves monitoring the patient closely for any signs of complications, such as bleeding or infection at the incision site. Continuous assessment of the ECMO/ECLS system is essential to ensure that it is functioning correctly and providing adequate support. Patients may require additional imaging or interventions based on their clinical status. Recovery will vary depending on the individual patient's condition and response to the procedure, and ongoing support and management will be necessary to optimize outcomes.

Short Descr	ECMO/ECLS REPOS PERPH CNULA
Medium Descr	ECMO/ECLS ECLS REPOS CENTRAL CNULA 6YRS & OLDER
Long Descr	Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed)
Status Code	Active Code
Global Days	000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66)	1 - Team surgeons could be paid, though...
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Inpatient Procedures, not paid under OPPS
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P2F - Major procedure, cardiovascular-Other
MUE	1

51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
78	Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
GC	This service has been performed in part by a resident under the direction of a teaching physician