Q&A: Documenting intubation and extubation times

Q: How do I document the start of mechanical ventilation if a patient is intubated in another emergency department (ED) before being transferred to our facility?

One of the most important—and often neglected—items in the documentation is the specific date and time that mechanical ventilation starts and stops, says Kim Felix, RHIA, CCS, director of education at e4health in Wyomissing, Pennsylvania. Mechanical ventilation starts at the time of endotracheal intubation or intubation through tracheostomy, she says. It ends at the time of extubation or discontinuance of ventilation for tracheostomy patients after the weaning process.

If a patient is intubated in your facility’s ED and later admitted, the start time is the intubation time, says Felix. “In that situation, code both the mechanical ventilation and endotracheal intubation,” she says.

However, if a patient is intubated in another hospital’s ED and transferred to your facility, the clock starts when they are admitted. In that case, only assign a code for the mechanical ventilation, says Felix.

When accurate start and stop times are included in the EHR, coders can more easily determine how many consecutive hours the patient spent on the ventilator, which impacts coding and reimbursement.

Editor’s note: This answer was excerpted from “Understanding proper coding and documentation for mechanical ventilation,” in the April 2024 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.