Question: A driver who was in a motor vehicle collision (MVC) arrives at the ED via ambulance with blunt trauma to his chest and abdomen from the seat belt and airbag; the patient is complaining of pain in his chest and severe abdominal pain due to the contusions. The physician performs a comprehensive history and examination and high complexity medical decision making. She then performs a focused assessment with sonography in trauma (FAST) exam and an electrocardiogram (ECG). Final diagnosis is "Contusions, chest/trunk." All of these services occurred on the same calendar date. What is the proper coding for this scenario?
Montana Subscriber
Answer: To keep this from getting too confusing, we'll list the procedure codes for this claim, and then list the ICD-9 codes separately. For this claim, you'll want to report the following CPT® codes:
Modifier 26 (Professional component) appended to 93308 and 76705 to show you are only coding for the physician's interpretation of the ultrasounds
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 was separate from the other services For this claim, you'll want to report the following ICD-9 codes:
