Wiki HELP!! PLEASE!!! GA for 4 month old Intubation

[ShandaAndrews10]

How do I code an Intubation for a four month old that we provided General Anesthesia for?

HISTORY OF PRESENT ILLNESS
This is a 16-week-old with multiple medical conditions including rhizomelic chondrodysplasia in addition to central and obstructive sleep apnea. The patient is currently in the neonatal ICU and is declining on nasal BiPAP. As such, they have asked the ENT Team to intubate the patient in the OR with the Anesthesia Team, as he is reported to have a very difficulty airway from prior operations.

DESCRIPTION OF PROCEDURE
The patient was brought to the OR and laid in the supine position. The Anesthesia Team breathed the patient down with sevoflurane gas to sedate the child. Once he was adequately sedated yet still breathing on his own, a Miller 1 blade was used to achieve a grade 4 view with significant cricoid pressure being applied. A 3.5 uncuffed ET tube was successfully inserted on the 1st attempt. At this time the patient was then turned back over to Respiratory Care and transferred back up to the NICU.


Thank you.

Shanda Andrews, CPC

 

[lcole7465]

How do I code an Intubation for a four month old that we provided General Anesthesia for?

HISTORY OF PRESENT ILLNESS
This is a 16-week-old with multiple medical conditions including rhizomelic chondrodysplasia in addition to central and obstructive sleep apnea. The patient is currently in the neonatal ICU and is declining on nasal BiPAP. As such, they have asked the ENT Team to intubate the patient in the OR with the Anesthesia Team, as he is reported to have a very difficulty airway from prior operations.

DESCRIPTION OF PROCEDURE
The patient was brought to the OR and laid in the supine position. The Anesthesia Team breathed the patient down with sevoflurane gas to sedate the child. Once he was adequately sedated yet still breathing on his own, a Miller 1 blade was used to achieve a grade 4 view with significant cricoid pressure being applied. A 3.5 uncuffed ET tube was successfully inserted on the 1st attempt. At this time the patient was then turned back over to Respiratory Care and transferred back up to the NICU.


Thank you.

Shanda Andrews, CPC

Since this doesn't have an ASA cross, you would need to find the most appropriate cross for the Intubation, CPT 31500. I've used in the past ASA 00320 for patient's age 1 year and older and 00326 for patient's younger than 1 year. Since there is no cross, documentation will need to be submitted for the medical necessity.