ED Coding and Reimbursement Alert
Check for High-Level E/M Before Coding FAST Exams
Documentation could even support critical care.
Given that most patients requiring focused assessment by sonography for trauma (FAST) exams have suffered extensive and traumatic injuries, don't be surprised if you see high-level ED E/Ms on FAST exam encounters.
You need to be able to recognize, however, that some cases fall short of the required elements.
A level-five E/M is a possibility for many FAST exam patients, so keep your eyes peeled for encounter details that could help justify 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).
In fact, FAST exam patients might even need critical care before the FAST exam in certain situations, explains Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.
Make Sure Encounter Meets All 99291 Elements
Before reporting critical care with a FAST exam,you'll need to satisfy the requirements for 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and possibly +99292 (... each additional 30 minutes [List separately in addition to code for primary service]). It is, however, possible in the ED.
Consider this detailed clinical example from Contreras:
A patient presents to the ED via EMS following a syncopal episode preceded by severe back pain: the patient was found unresponsive with a barely palpable pulse. EMS initiated advanced cardiac life support (ACLS) protocols in the field, and the patient regained a pulse prior to presentation.
The ED physician performs an exam, starts a normal saline drip, and orders a chest x-ray and lab work. The patient remains hypotensive, with systolic pressure in the 50s, so the physician orders a dopamine drip and orders a vascular surgery consult to evaluate the potential ruptured aortic aneurysm. The physician performs a FAST exam, showing a hugely enlarged aortic aneurysm with free fluid. Following the FAST exam, the patient is taken directly to the OR for a suspected ruptured abdominal aortic aneurysm. The final diagnosis is ruptured aortic aneurysm.
Encounter notes indicate that the physician spent 45 minutes providing critical care time exclusive of all other billable procedures. On the claim, you'd report the following:
• 99291 for the critical care
• 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study) for the first part of the FAST exam
• 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) for the second part of the FAST exam
• modifier 26 (Professional component) appended to 93308 and 76705 to show that you are coding only for the physician's services
• 441.3 (Abdominal aneurysm, ruptured) appended to 99291, 93308, and 76705 to represent the patient's condition.
Let Encounter Notes Do the E/M Level Driving
Caveat: The above scenarios are examples of what type of E/M a FAST exam patient might receive. This does not suggest that all patients requiring FAST exams will receive either a 99285 or 99291 E/M pre-exam.
Best bet: As always, choose your E/M code level based on the specifics of the ED patient encounter.
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