Hospital and Professional Charges and Reimbursement Patterns in Pediatric Extracorporeal Membrane Oxygenation

Area of Science:

• Critical Care Medicine
• Health Economics
• Pediatric Surgery

Background:

• Extracorporeal membrane oxygenation (ECMO) is a costly life-saving therapy.
• Understanding billing and reimbursement is crucial for financial sustainability.
• The impact of 2015 Current Procedural Terminology (CPT) code changes on pediatric surgical billing requires evaluation.

Purpose of the Study:

• Identify primary cost drivers in ECMO patient bills.
• Analyze reimbursement patterns for hospital and professional services.
• Assess the financial impact of 2015 CPT code modifications on pediatric surgeons.

Main Methods:

• Retrospective analysis of ECMO cases from 2008-2017 at a children's hospital.
• Detailed review of itemized hospital and professional billing data.

Main Results:

• Top charges included room rates, nitric oxide, medications, invasive monitoring, and lab tests.
• Average reimbursement was approximately 60% for hospital bills and 36% for professional bills.
• 2015 CPT code changes led to a 65% reduction in relative value units (RVUs) and a 46% decrease in professional charges, with commercial reimbursement dropping from 70% to 59%.

Conclusions:

• ECMO costs are primarily driven by non-ECMO related services and supplies.
• Implementing evidence-based management guidelines may reduce healthcare expenditure.
• Updated CPT codes devalue professional charges, impacting revenue and potentially limiting access to this critical therapy due to high infrastructure costs.