ED Coding and Reimbursement Alert

Seconds count with airway tube insertions, but take a few minutes to learn these important tips.

A frequent presenting problem in the emergency department is a patient having trouble breathing due to pulmonary disease, injury, or swelling of the throat tissues. You would typically report these encounters as high level ED visits or critical care because of the nature of the presenting problem, but you may also be able to report a procedure code if it is properly documented. Read on for advice on appropriately documenting to support your airway services procedure coding.

1. Determine Reason for Airway

"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 Granovsky, MD, CPC, FACEP, President of LogixHealth, an emergency medicine coding and billing company in Bedford, Massachusetts.

Sample scenario: You should look for documentation describing tube placement similar to the following example:

A 24 year old female is brought in by her boyfriend from a picnic in a nearby park. Her face shows signs of increasing swelling and she complains of having trouble breathing as if her throat is closing. She reports a history of reactions to bee stings that have escalated in severity since she was a child. She is not sure she was actually stung, but the boyfriend reports that there were bees in the area and that they were seated near a large flower garden.

The emergency physician orders an epinephrine injection, and since the patient had developed increasing respiratory distress, places a tube down her throat to maintain her airway. After obtaining that limited history due to her breathing issues, an examination shows no other indication for the allergic reaction and he finds a likely sting site on the back of her neck. The patient responds well to the epinephrine and the swelling begins to subside after 40 minutes after which she is admitted to the hospital. The physician documents 32 minutes of critical care time outside of separately billable procedures and provides a diagnosis of anaphylaxis due to the bee sting.

On the claim, you would report:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)
• 31500 (Intubation, endotracheal, emergency) for the tube placement
• 989.5 (Toxic effect of other substances, chiefly non-medicinal as to source, venom)
• E905.3 (Venomous animals and plants as the cause of poisoning and toxic reactions, hornets, wasps, and bees)

Apply the modifier 25 to 99291 to show that the intubation is separate from the critical care services.

2. Critical Care? Scan for Time Details

Remember that if the patient was reported as critical care, you must back out the time spent providing other procedures, such as intubation, from your total patient care time. Many payers want a statement in the documentation to that effect. Fortunately, most emergency physicians can place a tube rather quickly.

3. Identify Who Provided Tube

"If a patient with severe respiratory distress arrives by ambulance, check the chart to make sure the endotracheal tube was actually placed by the ED provider rather than by the paramedics to be sure the code assignment is appropriate," warns Granovsky.

Better training and standard of practice among paramedics has increased the number of patients that are intubated in the field before or during transport to the hospital. If the patient continues to decompensate in route, and the EMS providers have proper training, they will now often intubate the patient, including the use of paralytics and similar drugs that would be used in the hospital setting.

Bottom line: If the chart does not indicate that the tube was inserted in the ED by the emergency physician, you should verify the provider performing the placement before reporting the service.

4. Watch for Mask Use

Also be careful to watch for the use of only a laryngeal mask airway (LMA) to assist breathing. The laryngeal mask alone is not separately reportable. Code 31500 requires endotracheal intubation and the LMA sits above the trachea and does not go all the down and into the trachea. If the LMA is followed by endotracheal intubation, you may then report the standard 31500 code.

For example: A patient with congestive heart failure is becoming hypoxic. The physician attempts standard intubation but due to the patient's short neck, small mouth, and overall obesity, the physician is unable to place an endotracheal tube. An LMA is inserted as a rescue device and the patient is repositioned to overcome some of the anatomical difficulties. The physician then passes an endotracheal tube through the LMA and into the trachea; you may now report code 31500.

5. Don't Overlook Scopes

Other airway procedures performed in the ED include layrngoscopy (31575, Laryngoscopy, flexible fiber optic; diagnostic) and bronchoscopy (31622,

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]). Remember, however, that code 31575 has a CCI edit that prevents reporting in combination with endotracheal intubation.

So if a child presents to the ED with difficulty swallowing and breathing due to a suspected hard candy stuck in his throat, the emergency physician might use a flexible laryngoscope inserted nasally to visualize the blockage and determine if there was damage to the surrounding tissues. If the child's breathing is such that endotracheal intubation is required as well, you should report only the 31500 code.

Tips: Watch for these airway procedures in the chart documentation, as they can add additional revenue for the services rendered. The 2011 RVUs and payments for the codes covered are as follows.