Case
-T9-2A OPERATIVE REPORT, INTUBATION
LOCATION: Inpatient, Hospital
PATIENT: Russell Shergrud
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREPROCEDURE DIAGNOSIS: Acute respiratory failure
POSTPROCEDURE DIAGNOSIS: Acute respiratory failure
PROCEDURE PERFORMED: Intubation with a #8 endotracheal tube
The first attempt was with an 8.5 endotracheal tube, which just did not fit in the vocal cords. I was afraid of causing trauma, so we switched to a #8 endotracheal tube, which went in nicely. He had good return on the capnograph, and we eventually got O2 (oxygen) saturations up to 90%. It took 35 minutes to do that, to get his O2 stats back up from about 60% to over 90% once he was intubated.
I got here toward the middle of the respiratory arrest, so I do not think any sedation was given. A chest x-ray will be taken postprocedure to assure ourselves of a good placement.
T9-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 31500 (Intubation, Endotracheal, Tube) [see rationale for alternate
code]
ICD-10-CM DX: J96.00 (Failure/failed, respiration/respiratory, acute)
Explanation: The service is an intubation conducted during an emergency as indicated by the statement "I got here toward the middle of the respiratory arrest." The emergency intubation is reported with 31500. It would also be acceptable to code this as critical care services (99291 for 30-74 minutes). If critical care codes are used, the intubation would not be reported separately because intubation is bundled into the critical care codes.
The diagnosis is as stated in the Postprocedure Diagnosis section of the report as acute respiratory failure and reported with J96.00.

Case -T9-2A OPERATIVE REPORT, INTUBATION