ECMO Billing and FInancial Considerations: Key Lessons Volume 37 | Issue 1 | April 2026
Written by Katy Anderson   

ECMO Billing and Financial Considerations: Key Lessons

by Lovkesh Arora, MD, FASA, E-AEC
Chair, SOCCA CPC MCS/ECMO/CTICU Workgroup 
University of Iowa Hospitals & Clinics, Iowa City, IA
&
Suzanne Bennett, MD, FCCM
Secretary, Service Chief’s Advisory Council
Member, CPC MCS Subcommittee
Member, CPC Transplant Anesthesia Subcommittee
University of Cincinnati College of Medicine, Cincinnati, OH

Introduction

Extracorporeal membrane oxygenation (ECMO) remains one of the most resource-intensive yet life-saving therapies in critical care. While discussions often focus on outcomes and innovation, financial sustainability is equally essential to maintain program viability. As ECMO utilization expands, institutions must understand how outcomes, resource utilization, and reimbursement, cost structures, and patient mix interact to sustain both quality and access.

Drawing on the authors’ experience as medical directors of university-based ECMO programs, this article summarizes practical billing and financial considerations that significantly influence program performance, focusing on length of stay, run duration, payor mix, and cost drivers.

Length of Stay and ECMO Run Days

Length of stay (LOS) remains a key financial determinant for ECMO cases. Longer ECMO runs nearly always extend total LOS, driving higher resource consumption and narrowing contribution margins. Programs that maintain efficient workflows and structured daily goals tend to achieve better alignment between costs and reimbursement. Maintaining average stays below the Medicare Expected LOS has been associated with improved financial performance without compromising outcomes.

Typical ECMO hospitalizations may cost between $8,000 and $10,000 per day, with ICU stay, continuous ECMO management, and medication use comprising most expenses. While initial circuit and equipment costs are substantial, the ongoing ICU cost becomes dominant after the first several days on support.

Payor Mix and Reimbursement Variability

For small- to medium-sized ECMO programs, payor mix can be the single most important factor determining financial stability. A handful of under-reimbursed cases (e.g., Medicaid or self-pay) can markedly affect an annual balance sheet, whereas a few well-reimbursed commercial encounters can stabilize it.

Medicare and most governmental payors reimburse ECMO through Diagnosis-Related Group (DRG 003)–based payments, providing a fixed amount per hospitalization regardless of the actual cost. Commercial payors typically negotiate reimbursement as a percentage of billed charges, leading to significant variation.

Professional billing remains more nuanced. CPT codes distinguish between initiation (33946, 33947), the initial cannulation (such as 33952–33956 for peripheral cannulation) and the daily management codes (typically 33948–33949) that reflect the complexity of ongoing ECMO support. Accurate, precise documentation, including cannulation site, configuration (VA vs. VV), and physician involvement, directly influences compliant billing and appropriate reimbursement. As anesthesiologists increasingly lead ECMO decisions to cannulate, cannulation, transport, and daily ECMO and critical care management, familiarity and application with these codes is essential.

Programs that maintain awareness of their payer mix and proactively engage in contract negotiations and coding accuracy reviews are better positioned to remain sustainable. Collaboration between the ECMO clinical team and hospital finance departments ensures that billing reflects the complexity of care delivered.

Major Cost Drivers

Understanding and managing cost drivers is essential for ECMO program budgeting. The largest contributors typically include:

  • ICU stay and staffing (nursing, respiratory therapy, and critical care coverage)
  • 24/7 ECMO management and specialist support
  • Pharmaceuticals and blood products
  • Disposable circuit, cannulas and oxygenator components
  • Procedural and consultative costs (e.g., tracheostomy, vascular interventions, imaging)
  • Periodic review of cost data helps identify efficiency opportunities, such as supply optimization, medication standardization, and earlier readiness assessments for ECMO weaning or decannulation.

Strategies for Financial Sustainability

Financial stewardship need not conflict with clinical excellence. Successful ECMO programs typically share several operational strategies:

  • Continuous LOS monitoring: Real-time dashboards help identify outlier cases and guide proactive interventions.
  • Integrated finance and clinical leadership: Regular meetings between ECMO, finance, and coding teams enhance reimbursement accuracy.
  • Optimized staffing models: Aligning ECMO specialist coverage with case volumes balances safety with cost efficiency.
  • Data-driven resource use: Tracking medication, blood product, and equipment utilization informs budget forecasting and quality improvement.
  • Proactive payer engagement: Understanding each payor’s contractual terms and approval requirements reduces denials and payment delays.

When implemented consistently, these measures can preserve financial health while maintaining the high standards expected of ECMO centers.

References

  1. Oude Lansink-Hartgring A etal; Dutch Extracorporeal Life Support Study Group. Hospital Costs of Extracorporeal Life Support Therapy. Crit Care Med. 2016 Apr;44(4):717-23.

  2. Abrams D, Fan E. Lower Flow, Higher Costs? Recognizing Tradeoffs on the Spectrum of Extracorporeal Support for Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2023 May 1;207(9):1116-1118.

  3. Stokes JW etal: Disposable Component Selection in Extracorporeal Life Support: A Cost Analysis. ASAIO J. 2021 Sep 1;67(9)