Coding Endotracheal Intubation
A patient with respiratory failure may require endotracheal intubation (31500 Intubation, endotracheal, emergency procedure) for airway support. Patients with clinical conditions such as drug overdose, sepsis, and some neurological conditions also may require intubation for airway protection. The clinical note may reflect symptoms such as hypoxia, tachypnea, and respiratory distress.
Documentation of the intubation procedure may include “endotracheal” or “nasotracheal intubation,” a notation of the size of the tube (i.e., 7.0), and the location of the tube (e.g., 22 cm at the lip). Generally, there will be documentation stating CO2 indicator or X-ray confirmation of placement. There is no additional code for the use of sedation, which may be documented as RSI (rapid sequence induction), or for use of a scope (e.g., Glide scope) for assistance in the placement of the endotracheal tube. Be sure to review the documentation for a procedure note when there is notation of “patient placed on ventilator.”