ED Coding and Reimbursement Alert

Question: Another hospital brought a woman in respiratory failure to our emergency department because they couldn't intubate. Even with help from a partner, I couldn't intubate her either. I ultimately secured her airway with the fast trac laryngeal mask airway (LMA). Should I code this as a standard intubation, or should I append a modifier to reflect the difficult airway? Is there a code for use of an LMA?
     
Missouri Subscriber Answer: If you performed the second step and placed an ET tube through the LMA, you should definitely report code 31500 (Intubation, endotracheal, emergency procedure). Considering all the extra work -- and likely technical difficulties you encountered -- you may be able to append modifier -22 (Unusual procedural services) to earn payment for your physician's additional service. But you should also keep in mind that you may not get reimbursed for the additional work, because many payers have edits that don't recognize modifier -22 with 31500 -- check with your payer to be on the safe side.

If you don't append modifier -22, one way you could capture your extra work is to roll the minutes you spent supporting the patient with bag valve mask ventilation and insertion of the LMA in preparation for endotracheal intubation toward critical care.

The LMA fast trac is a terrific device that's gaining popularity in the ED to handle difficult airways. The device uses a laryngeal mask airway, which anesthetists use in the operating room for short cases, and involves placement of a diaphragm-like device deep in the pharynx (but not below the vocal cords or the trachea). This placement allows you to ventilate the patient and also makes a second step possible: placing a standard endotracheal tube through the LMA and into the trachea, completely securing the airway.

If your only service was the LMA placement, you should probably just consider this work part of your critical care minutes and not report 31500. The definition of 31500 is "endotracheal" intubation, and insertion of an LMA device doesn't include placement of the device in the trachea.