ED Coding and Reimbursement Alert

This exam requires a pair of procedures -- and don't forget about that E/M, either.

Coders that misfile a claim for a focused assessment with sonography in trauma (FAST) exam risk costing the practice twofold, as this procedure requires a pair of codes and a modifier to report correctly.Ride this FAQ to FAST exam success every time your ED provides the service:

1.When would the ED physician perform a FAST exam?

ED physicians perform FAST exams when they are evaluating patients for internal bleeding, "either hemo-peritoneum or in the pericardial sack surrounding the heart," explains Eli Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass.

Common presentations associated with FAST exams include the following, according Jennifer K. Curry, clinical manager for the department of emergency medicine for UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J.:

• blunt trauma to the trunk/abdomen, as in a motor vehicle
• accident (MVA)
• hypotension with abdominal pain
• severe abdominal pain radiating to the back (to rule out
• aortic dissection)
• abdominal pain with recent cardiac or vascular catheterization
• with access through the inguinal vascular system.

2.How Do You Code for the First Part of a FAST Exam?

The first portion of any FAST exam is a limited transthoracic echocardiogram to check for pericardial fluid, Berg explains. You'll report this portion of the FAST exam with 93308 (Echocardiography, transthoracic, real-time with image  documentation [2D], includes M-mode recording, when performed, follow-up or limited study).

3.How Do You Code for the Second Part of a FAST Exam?

Part II of the FAST exam "is a limited abdominal sonogram which is utilized to assess for the presence of free fluid in the abdomen," says Berg. Report this sonogram with 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Modifier alert: ED coders would typically apply modifier 26 (Professional component) to both 76705 and 99308 to show they are only reporting the professional component of the service.

"It is common that the hospital purchases the ED US machine directly," Berg says.

4.Are there Any Other Codes on FAST Exam Claims?

A FAST exam most likely comes with a separately reportable E/M service. "In the ED setting an E/M would typically be reported along with the FAST exam," confirms Berg. In some instances, providers might also perform and document a separate and formal chest cavity US, which you would report with 76604 (Ultrasound, chest [includes mediastinum], real time with image documentation).

Consider this example from Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Example: A patient arrives via ambulance post-MVC with a seatbelt injury to the abdomen. After a trauma survey, the physician performs a FAST exam, per advance trauma life support (ATLS) protocol. Notes indicate a comprehensive history and exam, along with high-complexity decision making. The physician documents hemoperitoneum, and the final diagnosis is ruptured spleen with severe parenchymal disruption.

On the claim, you would report the following:

• 99308 for the first part of the FAST exam
• modifier 26 appended to 99308 to show that you are only coding for the professional component of the ultrasound
• 76705 for the second part of the FAST exam
• modifier 26 appended to 99308 to show that you are only coding for the professional component of the study
• 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 ...) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to
• 99285 to show that the E/M and the FAST exam were separate services
• 865.04 (Injury to spleen; without mention of open wound into cavity; massive parenchymal disruption) appended to 99308, 76705 and 992854 to represent the patient's ruptured spleen.
• 567.29 (Peritonitis and retroperitoneal infections; other suppurative peritonitis) appended to 99308, 76705 and
• 992854 to represent the patient's peritonitis.

Service level potentially high: "If the patient was not taken to the OR emergently, the ED physician might perform a more comprehensive exam," Bucknam says. This level of E/ M service might even reach the level of critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes ...) if the patient who requires the FAST exam is critically injured, by CPT standards.