ED Coding and Reimbursement Alert

Check the chart for the reason for procedure any mention of using masks or scopes

An emergency department  patient is having trouble breathing from pulmonary disease, injury, or swelling of the throat tissues can be a scary scenario, but take a deep breath and concentrate on these tips to get the coding right every time. 

Airway related presentations are typically reported as high-level ED visits or critical care because of the serious nature of the presenting problem, but you may also be able to report a procedure code if it is properly documented.

Identify The Reason for Airway Problem

The most common airway-related procedure in the ED setting is endotracheal intubation, where the patient has a compromised airway that needs stabilization, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, and ED coding and billing company in Bedford MA. You should look for documentation describing tube placement to maintain the patient’s airway. The documented presenting problem may simply be severe shortness of breath or a more specific disease process such as COPD, asthma, or CHF. Other less common presentations include an allergic reaction such as a bee sting, an obstruction blocking the trachea, or perhaps an injury to the throat restricting the patient’s ability to breathe. Typically the procedure code for these scenarios is 31500 (Intubation, endotracheal, emergency procedure) for the tube placement, he adds.

Verify Who Placed The Tube

EMS providers are often trained to intubate patients in the field prior to arrival in the ED. If the patient arrives by ambulance, check the chart to make sure the endotracheal tube was actually placed by the ED provider rather than by the paramedics. 

Keep in mind: The ED physician may often re-intubate the patient upon arrival due to concern that the initial tube was not placed properly in the very challenging setting of the pre-hospital field environment. If the ED physician re-intubates the patient, look for a procedure note such as: “Poor chest rise, O2 sats decreasing, initial ET removed. Patient re-intubated by me with using glidescope, cords visualized, ET 23 cm at the lip with good end tidal CO2 and chest rise,” says Granovsky.

Look for Clues Such As Mention Of Masks Or Scopes

Be careful to watch for the use of only a laryngeal mask as a stop gap measure to manage the airway. The laryngeal mask alone is not separately reportable. However, if it used in additional to endotracheal intubation, report only the 31500 code. If no tube is placed, use of the laryngeal mask is included in the E/M code used to report the visit; most of these patients requiring LMA assistance will be critical care.

Also watch for these airway procedures in the chart documentation as they can add additional revenue.  Other airway procedures performed in the ED include 31575 (Layrngoscopy, flexible fiber optic; diagnostic) and 31622 (Bronchoscopy, rigid or flexible, fluoroscopic guidance, when performed; diagnostic, with cell washing when performed; separate procedure).  Remember, however, that 31575 has a CCI edit that prevents reporting in combination with endotracheal intubation. You can’t report both, says Granovsky.

Check the Clock For Possible Critical Care

Airway emergencies can usually qualify for critical care if the required time thresholds are met and appropriately documented. Tube placements procedures are not bundled into critical care, but don’t forget to subtract the time spent providing other procedures, such as intubation, from your documented critical care time. Most payers want a statement in the documentation to that effect, warns Granovsky.