A patient was emergently intubated for airway protection. Post intubation, the patient was noted to have bleeding from the oral cavity/oropharynx. The endotracheal tube (ETT) had pierced through the soft palate with a thin segment of circumferential tissue around the tube. The provider’s impression states, “Traumatic intubation resulted in soft palate injury involving ETT.” The thin cuff of soft palate tissue was released at bedside and the mouth was packed. What are the appropriate diagnosis codes for this case? Is it appropriate to assign an injury code, for the pierced soft palate due to traumatic ETT intubation?
Assign code K91.72, Accidental puncture and laceration of a digestive system organ or structure during other procedure, and code Y65.8, Other specified misadventures during surgical and medical care, to capture the traumatic ET intubation resulting in soft palate injury. Traumatic injury codes should not be assigned for injuries that occur during, or as a result of, a medical intervention.