How to code endotracheal intubation
Endotracheal intubation (EI) is an emergency procedure that?s often performed on people who are unconscious or who can?t breathe on their own. EI maintains an open airway and helps prevent suffocation.
In a typical EI, the paitent first is given a heavy anesthetic. Then, a flexible plastic tube is placed into the trachea, or windpipe, through the mouth or nose to help the paitent breathe.
The trachea, also known as the windpipe, is a tube that carries air to the lungs. It?s about 4 inches long and 1 inch wide. It begins just under the larynx, or voice box, and extends down behind the breastbone, or sternum. The trachea then divides into two smaller tubes called bronchi. Each tube connects to a lung.
The trachea is made up of tough cartilage, muscle, and connective tissue. Its lining is composed of smooth tissue. Each time a breath in is taken, the windpipe gets slightly longer and wider. Then returns to its normal size during exhaling.
The patient can have difficulty breathing or may not be able to breathe at all if the trachea is blocked or damaged. This is when EI is necessary.
A patient with respiratory failure may require endotracheal intubation (31500 Intubation, endotracheal, emergency procedure) for airway support. Patients with clinical conditions such as drug overdose, sepsis, and some neurological conditions also may require intubation for airway protection. The clinical note may reflect symptoms such as hypoxia, tachypnea, and respiratory distress.
Documentation of the intubation procedure may include ?endotracheal? or ?nasotracheal intubation,? a notation of the size of the tube (i.e., 7.0), and the location of the tube (e.g., 22 cm at the lip). Generally, there will be documentation stating CO2 indicator or X-ray confirmation of placement. There is no additional code for the use of sedation, which may be documented as RSI (rapid sequence induction), or for use of a scope (e.g., Glide scope) for assistance in the placement of the endotracheal tube. Be sure to review the documentation for a procedure note when there is notation of ?patient placed on ventilator.?