ED Coding and Reimbursement Alert

Do you know which techniques qualify for 31500?

When your ED physician performs endotracheal intubation, there are several different techniques they could use to insert the breathing tube that would qualify for 31500 (Intubation, endotracheal, emergency procedure).

The trick is being able to recognize these techniques as 31500-eligible. This takes procedural and clinical knowledge, as well as smarts about what CPT^® considers a 31500 procedure.

Read on for more information on coding endotracheal intubation in the ED.

ED E/M Precedes Endotracheal Intubation

When your physician treats a patient that ends up needing endotracheal intubation, there will certainly be a significant, separately identifiable evaluation and management (E/M) service that comes before the intubation. The physician will need to determine the status of the patient’s airway and their breathing during this service, which you’ll, at minimum, be able to report with an ED E/M code from 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making).

This E/M might even qualify for critical care, so be on the lookout for instances in which you could use 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)) for the pre-intubation E/M.

Caveat: Endotracheal intubation does not automatically make the patient critical care-eligible. “However, the indications for intubation — respiratory failure or to protect the airway — can frequently be an indicator of critical care service,” explains Hamilton Lempert, MD, FACEP, CEDC, vice president of coding policy at TeamHealth.

The critical care E/M is not a given, however. The patient needs to fit the definition of critically ill or injured. Also, “critical care requires a certain number of minutes and the procedure itself needs to not be included in that total number of minutes. So, it is possible that a patient could require endotracheal [intubation] but not qualify for critical care,” says Lempert.

No matter what: When reporting the pre-intubation E/M, be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code so the payer knows that a significant, separately identifiable E/M took place before the intubation.

Remember that if endotracheal intubation is reported along with critical care, you must deduct the time spent providing that service from your reported critical care time.

These ICD-10 Codes Often Mark 31500 Claims

While there could be a number of diagnoses that prove medical necessity for 31500, here is a sampling of some of the ICD-10 codes you might see to justify the use of endotracheal intubation:

• J22 (Unspecified acute lower respiratory infection)
• J39.8 (Other specified diseases of upper respiratory tract)
• J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation)
• J95.87 (Transfusion-associated dyspnea (TAD))
• J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia)
• J96.01 (Acute respiratory failure with hypoxia)
• J96.02 (Acute respiratory failure with hypercapnia)
• J96.90 (Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia)
• J96.91 (Respiratory failure, unspecified with hypoxia)
• J96.92 (Respiratory failure, unspecified with hypercapnia)
• J98.01 (Acute bronchospasm)
• J98.09 (Other diseases of bronchus, not elsewhere classified)
• J98.8 (Other specified respiratory disorders)
• P22.8 (Other respiratory distress of newborn)
• P22.9 (Respiratory distress of newborn, unspecified)
• P28.89 (Other specified respiratory conditions of newborn)
• R06.81 (Apnea, not elsewhere classified)
• R09.01 (Asphyxia)
• R09.02: (Hypoxemia)
• T17.400A (Unspecified foreign body in trachea causing asphyxiation, initial encounter)
• T71.XXXA (Asphyxiation, initial encounter)
• R06.9 (Unspecified abnormalities of breathing)
• U07.1 (COVID-19)

Note: This is not an exhaustive list; there could be other diagnoses that patients receive that support endotracheal intubation. Further, inclusion on this list does not guarantee the code will cover 31500. Always code based on the encounter notes, and check with your payer if you have any questions on medical necessity.

Report 31500 for These Techniques

Lempert reminds coders that 31500 covers a wide variety of techniques in which endotracheal intubation is achieved. “The question is what procedures are eligible for this code,” he says. “There are a variety of ways of performing endotracheal intubation, including, but not limited to”:

Direct laryngoscopy: The ED physician inserts a laryngoscope into the patient’s mouth and throat to provide a clear view of the larynx, or voice box, and the surrounding structures. This technique allows physicians to diagnose and visualize abnormalities or issues related to the airway, such as vocal cord paralysis, tumors, or the presence of a foreign body. It can also be performed during endotracheal intubation to guide the placement of the endotracheal tube into the trachea.

Video laryngoscopy: The physician inserts a laryngoscope equipped with a small camera and light into the patient’s mouth and throat. This allows the healthcare provider to visualize the larynx, or voice box, and the surrounding structures on a video monitor. Video laryngoscopy is commonly employed during endotracheal intubation to help guide the placement of the tube into the trachea, and it can also be used to diagnose and evaluate airway abnormalities or obstructions.

Bougie insertion: The physician inserts a bougie into the patient’s trachea to help guide the placement of the endotracheal tube. A bougie is a flexible, slender, and cylindrical medical instrument often used as a guide during endotracheal intubation, particularly in difficult airway situations.

Nasal tracheal intubation: The physician inserts a tube through the nose that passes down into the trachea. This allows for an open airway and is commonly used to ensure adequate ventilation and oxygenation in patients who cannot breathe on their own. The tube is usually connected to a ventilator, which delivers oxygen and removes carbon dioxide from the lungs. Nasal tracheal intubation can be more comfortable for patients compared to oral tracheal intubation, especially for prolonged periods of ventilation.

Digital intubation: The physician inserts an endotracheal tube into the trachea using their fingers to guide the tube, rather than relying on instruments like a laryngoscope. This method may be used in emergency situations or when conventional intubation techniques are not possible, such as when a laryngoscope is not available, or when the patient’s anatomy makes it difficult to visualize the airway.

“All of these procedures qualify for 31500,” Lempert confirms. Many coders will also count laryngeal mask airway (LMA) placement as 31500 — but you might want to check your payer contracts first.

LMA, maybe: “Although an LMA does not go through the vocal cords, you are still covering the trachea and providing air through that tube. The risks and benefits of LMA placement are the same as endotracheal intubation,” explains Lempert. Still, this might not be 31500-eligible for some payers, so be sure to check before reporting LMA placement with 31500.

Don’t Code These Services Separately

There is guidance from both coding bodies regarding services you definitely should not report along with 31500.

From CMS: According to the Centers for Medicare & Medicaid Services (CMS), “an emergency endotracheal intubation procedure (CPT code 31500) is normally followed by a chest radiologic examination to confirm proper positioning of the endotracheal tube. A chest radiologic examination CPT code (e.g., 71045 [Radiologic examination, chest; single view], 71046 [Radiologic examination, chest; 2 views]) shall not be reported separately for this radiologic examination.”

From CPT^®: Per CPT^®, “Visualization of the airway is a component part of an endotracheal intubation, and CPT codes describing procedures that visualize the airway (e.g., nasal endoscopy, laryngoscopy, bronchoscopy) should not be reported with an endotracheal intubation. It is a misuse of diagnostic and therapeutic endoscopy codes to report visualization of the airway for endotracheal intubation.”