Endotracheal Intubation

CPT 31500
Approach Direct Laryngoscopy
Preoperative Diagnosis:

[Respiratory failure / airway protection / hypoxic respiratory failure / hypercarbic respiratory failure / decreased level of consciousness / GCS ≤8 / impending airway loss]

Postoperative Diagnosis:

Same

Procedure Performed:

Endotracheal intubation via direct laryngoscopy [/ video laryngoscopy]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/RT/resident name]

Anesthesia:

RSI: [succinylcholine / rocuronium] + [etomidate / ketamine / propofol], [fentanyl if hemodynamically stable]

Indications:

The patient is a [age]-year-old [male/female] with [acute hypoxic / hypercarbic respiratory failure / declining mental status / GCS [X] / impending airway loss] requiring emergent endotracheal intubation for airway protection and mechanical ventilatory support. The nature of the procedure, risks, and the emergent indication were [explained to the patient / discussed with the family / not obtainable given emergent circumstances].

Findings:

The patient was [cooperative / unresponsive / combative] prior to RSI. Airway exam: Mallampati [I-IV], mouth opening [adequate / limited], neck mobility [normal / limited], [other]. Cormack-Lehane grade [I / II / III] view was obtained on laryngoscopy. The vocal cords were [fully / partially] visualized. A [7.0 / 7.5 / 8.0] mm endotracheal tube was placed on [first / second] attempt. Tube position was confirmed by [end-tidal CO2 waveform / bilateral breath sounds / CXR showing tip at carina minus 2 cm].

Description of Procedure:

Informed consent was [obtained / waived given emergent circumstances]. Pre-oxygenation was performed with a non-rebreather mask [or bag-valve-mask] for [3–5] minutes, achieving SpO2 of [X]%. The airway was assessed: [Mallampati class, mouth opening, neck mobility, thyromental distance, BMI, other difficult airway predictors].

Rapid sequence induction was performed: [fentanyl X mcg IV] was administered, followed by [etomidate X mg IV / ketamine X mg IV] for induction and [succinylcholine X mg IV / rocuronium X mg IV] for neuromuscular blockade. Cricoid pressure was [applied / not applied].

Direct [or video] laryngoscopy was performed with a [Macintosh size 3 / Miller size 2 / video laryngoscope] blade. Cormack-Lehane grade [I / II] view was obtained. The glottis was [fully / partially] visualized. A [7.5] mm cuffed endotracheal tube with a stylet was advanced through the vocal cords under direct vision. The tube was confirmed to pass between the cords. The stylet was removed.

The cuff was inflated to [5–10] cmH2O. Tube placement was confirmed by: (1) end-tidal CO2 waveform with [X] mmHg, (2) bilateral equal breath sounds on auscultation, (3) absence of epigastric sounds, and (4) rising SpO2. The tube was secured at [23] cm at the lip with a Thomas holder [or tape]. Ventilator settings were initiated. A chest radiograph confirmed tube tip approximately 2–3 cm above the carina.

Complications:

None

Specimens:

None

Estimated Blood Loss:

None

Drains:

[7.5] mm ETT at [23] cm at the lip, connected to mechanical ventilation

Disposition:

The patient was placed on mechanical ventilation with initial settings: [AC/VC, TV 6 mL/kg IBW, RR 14, FiO2 100%, PEEP 5]. SpO2 and ETCO2 were monitored continuously. ABG was obtained 30 minutes after intubation. The patient was monitored in the [ICU].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Endotracheal intubation via *** laryngoscopy
ATTENDING: ***, MD/DO
ASSISTANT: ***
MEDICATIONS: RSI: *** mg etomidate/ketamine + *** mg succinylcholine/rocuronium IV

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** requiring emergent intubation for ***. Consent: ***.

FINDINGS: Mallampati ***, C-L grade *** view. *** mm ETT placed on *** attempt. Confirmed by ETCO2 waveform, bilateral breath sounds, CXR.

PROCEDURE:
Pre-oxygenation to SpO2 ***% via NRB/BVM x*** minutes. Airway assessed: Mallampati ***, mouth opening ***, neck mobility ***.

RSI: *** mg *** (induction) + *** mg *** (paralytic) IV. *** laryngoscopy with *** blade. C-L grade *** view. *** mm ETT advanced through cords under direct vision. Cuff inflated. Confirmed: ETCO2 *** mmHg, bilateral breath sounds equal, SpO2 rising. Tube secured at *** cm at lip. CXR: tip *** cm above carina.

Initial vent settings: AC/VC, TV *** mL, RR ***, FiO2 ***%, PEEP ***.

COMPLICATIONS: None
DISPOSITION: Patient on mechanical ventilation, monitored in ICU.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Video Laryngoscopy (GlideScope / C-MAC)

Given [anticipated difficult airway / obesity / limited neck mobility / prior difficult intubation], video laryngoscopy was performed using a [GlideScope / C-MAC] with a [hyperangulated / standard] blade. A Cormack-Lehane grade [I / II] view was obtained on the video screen. A pre-shaped stylet was used to navigate the acute angle. The tube was confirmed in the trachea by ETCO2 and bilateral breath sounds.

Failed Airway: Surgical Airway (Cricothyrotomy)

After [number] failed laryngoscopy attempts with [direct / video] laryngoscopy and failed [LMA / bougie-assisted] rescue attempts, a cannot-intubate, cannot-oxygenate (CICO) situation was declared. An emergent surgical cricothyrotomy was performed: the cricothyroid membrane was identified by palpation, a vertical skin incision was made, and a horizontal stab incision through the membrane was performed. A [6.0] mm cuffed ETT [or tracheostomy tube] was inserted and confirmed by ETCO2 and bilateral breath sounds.

Awake Fiberoptic Intubation

Given the anticipated difficult airway, awake fiberoptic intubation was performed. The posterior pharynx and supraglottic structures were anesthetized with topical [4% lidocaine spray / nebulized lidocaine]. The patient was cooperative throughout. A fiberoptic bronchoscope was passed through a [7.5] mm ETT and advanced nasally [or orally] through the vocal cords under direct visualization. The ETT was railroaded over the scope into the trachea. The scope was removed, cuff inflated, and position confirmed by ETCO2 and CXR.

Charting Tips
  • Document ETT confirmation by at least two methods. ETCO2 waveform is the gold standard. Auscultation alone is insufficient. State the ETCO2 value and that bilateral breath sounds were equal with absence of epigastric sounds.
  • Record the Cormack-Lehane grade. This documents the difficulty of the airway view and is critical for future airway planning. A grade III or IV view should trigger an anesthesia or ENT difficult airway flag in the chart.
  • Document medications, doses, and sequence for RSI. In the event of hemodynamic compromise or adverse reaction, medication documentation is essential. Also note who administered medications and who performed laryngoscopy.
Billing Tips
  • Bill 31500 for emergency endotracheal intubation (2.93 wRVU, 0-day global). This code is specifically for emergency airway placement — not for elective intubation by anesthesia for a scheduled case.
  • 0-day global: separately billable from same-day E/M or critical care. When performed as part of critical care management, it is typically bundled into the critical care time (99291/99292) and not separately billed.
  • If the intubation is the only significant service performed, 31500 is the primary code. If performed as part of a broader resuscitation, document the time spent to determine whether critical care billing (99291) is more appropriate and captures more value.
  • Video laryngoscopy does not change the CPT code — 31500 applies regardless of technique. Document the device and blade type used for the procedural record.
  • Fiberoptic-assisted intubation in a patient with difficult airway may justify a separate code (31622 diagnostic bronchoscopy) if a full bronchoscopic intubation was performed, but this requires documentation that bronchoscopy was the primary intubation technique.