Revenue Cycle Insider

Remember, a high-level ED E/M will likely occur during these encounters.

When a patient presents to the emergency department (ED) after a traumatic accident, the ED physician might need to check for internal bleeding or abdominal/trunk trauma. In order to assess these areas of patient anatomy, the physician will often turn to a focused assessment sonogram in trauma (FAST) exam.

The basics: A FAST exam is “generally performed when a patient has experienced high-force mechanism injuries such as a motor vehicle accident or a significant fall,” explains Sarah Todt, RN, CPMA, CPC, CEDC, CPCO, executive director of revenue integrity at LogixHealth in Bedford, Massachusetts.

Check out the quickest way to code FAST exams correctly.

FAST Decision Starts With ED E/M

The decision to perform a FAST exam will come during the ED evaluation and management (E/M) service, which can come in at a high level. “Generally, a patient who requires a FAST exam will meet high medical decision making,” explains Todt. That could mean a highly complex case with a very sick patient and potential reporting of99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) or even 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) if the encounter meets the criteria for critical care.

A provider will base the FAST exam decision on the history and exam portion of the E/M, “including the mechanism of injury and current symptoms,” says Hamilton Lempert, MD, FACEP, CEDC. “The FAST exam is very good at finding abnormalities in trauma patients, but it is not used on every patient. They need to have the right symptoms to go along with the history. Sometimes that history can trump the physical exam, such as a patient with a distracting injury and a concerning mechanism of injury,” he explains.

Know Components of FAST Exam

A FAST exam isn’t one exam with a single CPT^® code, Todt explains. “Rather, it is comprised of two or three ultrasound studies.”  These studies combine to form the FAST exam, which focuses on four major internal areas (or “views”):

• Pericardial: This view can detect fluid around the heart
• Right upper quadrant (RUQ): This view is used to look for fluid around the liver and kidneys
• Left upper quadrant (LUQ): This view checks for fluid around the spleen and kidney
• Pelvic: This view will check for fluid in the pelvis, specifically around the bladder.

The first part of a FAST exam is an echocardiography, which you’ll report with 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study). This part of the exam is performed to check for cardiac tamponade or pericardial effusion.

The next part of the FAST exam is one or two ultrasounds (US), depending on the patient’s status. In addition to the echocardiography, they will need an abdominal or chest US — or both. You’ll code this part of the exam with one or both of the following codes:

• 76705 (Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
• 76604 (Ultrasound, chest (includes mediastinum), real time with image documentation)

Modifier alert: In the ED setting, you’ll append modifier 26 (Professional component) to all three of the above-listed codes, to show that you are only coding for your physician’s services, not the use of the equipment.

eFAST likely means all 3: A term that you might see in the notes is eFAST. This represents an extended FAST exam and frequently represents the performance of all three FAST exam components.

Check Out This Clinical Example

A patient presents after a motor vehicle accident with significant pain and bruising in the chest and abdominal area. The emergency physician is concerned about internal trauma and orders ultrasound studies of the chest and abdomen to rule out any internal injuries that would require further treatment, such as cardiac contusion or other organ damage. The patient was admitted with a cardiac contusion and  a bruised liver for further treatment. The emergency physician interpreted both studies and billed for those, so those points could not also be counted in the data column but a level 5 ED evaluation and management (E/M) service was justified based on the cost of poor quality analysis (COPA) and Risk columns points of the medical decision making (MDM) grid in the CPT^® manual.

 On the claim, report: 

• 99285 for the ED E/M service 
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99285 to show that the ED E/M and the FAST exam were significant, separately identifiable services
• 93308 for the echocardiography
• 76705 for the US
• If the test is performed as an eFAST exam, you would also report 76604
• Modifier 26 appended to 93308 and 76705 to show that you are only reporting the professional component of the code
• S26.91XA (Contusion of heart, unspecified with or without hemopericardium, initial encounter) appended to 99285, 93308, and 76705 for the heart contusion
• S36.112A (Contusion of liver, initial encounter) appended to 99285, 93308, and 76705 for the liver contusion.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC