ED Coding and Reimbursement Alert

Some ultrasound techniques are still new enough to emergency medicine that EDs don't always know the coding ropes - but that's no reason to leave reimbursement money on the bedside table.

At a recent American College of Emergency Physicians (ACEP) coding and reimbursement meeting, Dennis Beck, MD, FACEP, chairman of the ACEP Reimbursement Committee and CEO of Beacon Medical Services, asked attendees how many groups were doing ultrasounds, and about 30 percent of the attendees raised their hands. "Then I asked how many people were coding and billing for ultrasounds done in their EDs, and no hands went up," Beck says.

Historically, trauma surgeons and ED physicians haven't coded for these exams, says Stephen Hoffenberg, MD, FACEP, chairman-elect of the ultrasound section of ACEP and president of CarePoint, a 150-physician emergency group in Denver. "They just do them."

Primary Indications in the ED

Ultrasound is an evolving standard of care in emergency medicine, Hoffenberg says, and it has the extra advantage of being available at bedside. Bedside ultrasound in the ED can significantly accelerate patient care. "It's very quick to perform and it gives you essential diagnostic information that can be put into a clinical algorithm that will drive the care without requiring the patient be moved from the resuscitation suite to another part of the hospital."

Little guidance, however, has been provided in understanding the key elements of the coding or reimbursement for ultrasound procedures. CPT coding for many ultrasound procedures is straightforward, but in emergent settings unique variations arise.

ACEP policy specifically supports the use of ultrasound imaging by emergency physicians for several conditions: thoracoabdominal trauma, abdominal aortic aneurysm, pericardial effusion, ectopic pregnancy, and evaluation of renal and biliary tract disease. (Use of Ultrasound Imaging by Emergency Physicians [policy number 400121]).

Speedy Coding for FAST Exams

Emergency physicians frequently evaluate thoracoabdominal trauma using a two-part ultrasound examination. This examination is referred to by the acronym FAST, focused assessment by sonography for trauma.

"The first thing to understand about the exam," Hoffenberg says, "is that it's not a single procedure; it's actually a clinical approach to patients with blunt or penetrating trauma." Because of this definitional anomaly, he cautions, "you can't go to CPT and find a code for the FAST exam because it doesn't exist." Emergency coders need to understand that the FAST exam is not a single ultrasound procedure but a clinical approach to the trauma patient. However, two separate CPT codes describe limited ultrasound exams composing the FAST exam.

Two Limited Parts of a FAST Exam:93308 and 76705

A FAST exam is composed of two separately identifiable procedures: One is a limited transthoracic echocar-diogram, the second is a limited transabdominal ultrasound. Both components are required to do a complete FAST exam. A limited study addresses only a single quadrant or a single diagnostic problem, while a complete study attempts to visualize and evaluate all of the major structures within the anatomic region.

The first component of the FAST examination looks for heart activity and pericardial fluid; in other words, it is a limited transthoracic echocardiogram. It is directed to a single diagnostic problem - identifying the presence or absence of pericardial fluid. The cardiac evaluation generally employs a sub-xiphoid ultrasound window. The thoracic portion of the exam is coded as 93308 (Echocar-diography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study).

The exam continues with the abdomen, where the goal is to look for free fluid in the abdomen or hemoperi-toneum, Hoffenberg says. This second FAST exam component uses three separate ultrasound windows. Although the emergency doctor visualizes multiple body areas and organs, the abdominal portion of the examination is directed to a single diagnostic problem - identifying the presence or absence of free intraperitoneal fluid and therefore is defined as a limited study. The abdominal portion of the FAST exam is coded as 76705 (Ultrasound, abdominal, B-scan and/or real time with image documentation; limited (e.g., single organ, quadrant, follow up).

In both phases of the typical ED FAST exam, because the physician's attention is restricted to detecting the presence or absence of pericardial or intraperitoneal fluid, the individual procedures are limited studies. If you look at the definitions for codes 76705 and 93308, you will see that they are defined as limited studies, so no reduced-services modifier is required.

For both portions of the FAST exam, use the -26 (Professional component) modifier to indicate the professional component of the exam, Hoffenberg instructs ED coders. Hoffenberg also reminds coders that "everything has to be done right at one time if you're going to code and bill for it. You can't pick the right code and not worry about documentation or not worry about establishing medical necessity through appropriate ICD-9 codes."

Even though some ED groups may own the machines, says Michael Granovsky, MD, CPC, chief financial officer of Greater Washington Emergency Physicians in suburban Maryland, they are strongly advised to seek legal advice before using global service codes without modifier -26 because hospital-based physicians billing for the technical component of studies are very tightly regulated by fraud and abuse statutes.

ED Docs and Trauma Surgeons on the FAST Track

Hoffenberg says he is frequently asked whether both ED physicians and trauma surgeons may code and bill for FAST exams performed on the same patient. Simply put, he says, "it depends on why they're both doing it."

A second physician may code and bill a repeat examination for the same patient on the same date; however, the second physician should use modifier -77 (Repeat procedure by another physician) - if that physician is of a different specialty or not part of your group. Both physicians must document the medical necessity for each examination performed.

For example, an ER physician does an initial FAST exam that is negative (he finds no fluid), but 30 minutes later the patient becomes tachycardic and hypotensive. Either that emergency physician or a trauma surgeon repeats the exam to look for fluid, documenting that a repeat exam was done because the patient's clinical condition changed. This is a justifiable - and therefore billable - exam, Hoffenberg says.

The indications for a repeat FAST examination on the same patient encounter might include such factors as the development of hemodynamic instability, a falling hematocrit, or increased abdominal pain/tenderness in a patient who had a negative initial FAST examination.

Repeating a FAST examination to confirm the finding of another provider might be clinically appropriate for the trauma surgeon who is going to operate, Hoffenberg says, but from a billing and coding point of view, there is no medical necessity for the second study.

Remember that physicians of the same specialty in the same group, or working for the same employer, are often considered to be the same physician from a billing perspective. If the "same physician" repeats an examination, then modifier -76 (Repeat procedure by same physician) is used.