You Be the Coder: Intubation and Extubation by Different Groups

Question: Our anesthesiologist extubated a patient who was intubated by a physician in a different group. How should I report the extubation?

California Subscriber
Answer: CPT Codeshas a code for intubation (31500, Intubation, endotracheal, emergency procedure) but no  code for extubation. If you have enough documentation, you can bill an E/M service. Code 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; medical decision-making that is straightforward or of low complexity) is the most likely code for this case (though check the documentation to see if you should code a consult or ICU visit instead).

If the physician did not document enough to merit coding an E/M visit, report 31599 (Unlisted procedure, larynx) and file with the documentation.