ED Coding and Reimbursement Alert

Question A patient reports to the ED after crashing his snowmobile into another snowmobile. He was unconscious when he arrived, and had signs of generalized trauma on his abdomen (bruising). The patient awakes while being examined and complains of severe abdominal pain. The physician performs a level-five E/M, then conducts a FAST exam. Should I attach modifier 25 to the E/M code, or is that unnecessary?

Maine Subscriber

Answer: It depends on the insurer. When the physician performs an E/M, then conducts a FAST (focused assessment by sonography for trauma) exam, you will likely have to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

But not all payers require the modifier in this instance. If you are unaware of the insurer's specific policy on this issue, check your contract before filing the claim.

Suppose the insurer requires modifier 25. In this case, you would report the following:

- 93308 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study) for the thoracic portion of the FAST exam

- modifier 26 (Professional component) appended to 93308 to show that you are coding only for the professional service

- 76705 (Ultrasound, abdominal, real-time with image documentation; limited [e.g., single organ, quadrant, follow-up]) for the abdominal study

- modifier 26 appended to 76705 to show that you are coding only for the professional service.

- 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components ...: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the E/M.

- modifier 25 appended to 99285 to show that the FAST exam and the E/M were separate services.

- 789.07 (Abdominal pain; generalized) linked to 93308, 76705 and 99285 to represent the patient's abdominal pain.

- 922.2 (Contusion of trunk; abdominal wall) linked to 93308, 76705 and 99285 to represent the patient's abdominal issues.

- E820.0 (Nontraffic accident involving motor-driven snow vehicle; driver of vehicle other than motorcycle) linked to 93308, 76705 and 99285 to represent the cause of the patient's injuries.