ED Coding and Reimbursement Alert

Are you familiar with the term eFAST?

Trauma patients are a given in the ED setting, and a number of the patients who report with traumatic impact injuries are candidates for a FAST exam.

There are several components to a focused assessment sonogram in trauma — or FAST — exam. When your provider performs the exam, you’re going to need to be ready to report multiple codes, depending on the situation.

“A FAST exam does not have its own CPT^® code but rather it is comprised of two or three ultrasound [US] studies,” explains Sarah Todt, RN, CPMA, CPC, CEDC, CPCO, executive director of revenue integrity at LogixHealth in Bedford, Massachusetts. For more information on coding FAST exams from start to finish, check out the advice below.

Look to These Trauma Px for FAST Exam

Generally, the ED physician will perform a FAST exam “when a patient has experienced high-force mechanism injuries such as a motor vehicle accident or a significant fall,” Todt explains.

Coding part 1: The first part of the FAST exam is always an echocardiography, which you’d report with 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study).

Coding part 2: A FAST exam can include one (or both) of the following codes:

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

eFAST exam: Todt tells of another term often used to represent these exams: “eFAST, which indicates extended FAST and often represents the performance of all three studies.”

Look for Other Services During FAST Exam

The ED physician will decide to perform a FAST exam based on the history, including the mechanism of injury and current symptoms, that they find during an evaluation and management (E/M) service, such as 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (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).

“A FAST exam will be performed to evaluate for life-threatening internal injuries including cardiac tamponade, great vessel injuries, and organ injuries,” says Todt.

There will also be opportunities to code services outside of a FAST exam. “All other services may be reported as performed. An E/M service will be reported in addition to the FAST studies. Generally, a patient who requires a FAST exam will meet high medical decision making criteria and support 99285 or even critical care and support 99291 [Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes],” according to Todt.

During a FAST exam session, the physician might also perform several other procedures, including:

• 31500 (Intubation, endotracheal, emergency procedure)
• 32551 (Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure))
• 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)

Note: These procedures are not automatic when a provider performs a FAST exam, and they aren’t the only procedures your provider might utilize during a FAST exam. Always code to the notes, and ask a provider if you have any questions about additional services during a FAST exam.

Check Out This Clinical Scenario

To illustrate how FAST exam coding works, consider this clinical example from Todt:

42-year-old arrival via EMS s/p MVA. Patient was restrained driver who was traveling approx. 35 mph when they were on the passenger side by another vehicle in traffic on highway.

airbag deployment. Pt now complains of chest and generalized abdominal discomfort. Denies head trauma or other complaints.

Physical exam reveals bruising across chest in a seatbelt pattern. Minor chest wall tenderness. Abdomen soft but mildly tender. BS + x4. Neuro: Awake, alert and oriented x3.

MDM: Trama labs: CBC with differential, CMP, drug screen, Type and screen, PT/PTT. IV NS at 100cc/hr. IV MS 4 mg. EKG no ST elevation, no ectopy per my interpretation.

Differential diagnosis: Intra-abdominal injury, pneumothorax, hemothorax

FAST exam by ED Provider

Abdominal limited: No free fluid in RUQ and LUQ

Cardiac: No pericardial fluid, no evidence of cardiac tamponade

Thoracic: no pneumo/hemothorax identified

Permanent images were captured and electronically recorded.

Progress: Patient’s pain is improved able to ambulate. Will discharge with return precautions.

Diagnosis: chest wall contusion post MVA

CPT^® Coding:

For this claim, you would report:

• 93308 for the echocardiography
• 76705 for the abdominal US
• Modifier 26 (Professional component) appended to 76705 to show you are only coding for your providers services, not the FAST exam equipment use
• 76604 for the chest US
• Modifier 26 appended to 76604 to show you are only coding for your providers services, not the FAST exam equipment use.
• 99285 (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) for the E/M
• 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 E/M was a significant and separate service from the FAST exam.

ICD-10 Coding:

For this claim, you would report:

• S20.219A (Contusion of unspecified front wall of thorax, initial encounter) appended to 99308, 76604, and 99285 to represent the patient’s chest injury
• R10.817 (Generalized abdominal tenderness) appended to 76705 and 99285 to represent the patient’s abdominal injury
• V49.40XA (Driver injured in collision with unspecified motor vehicles in traffic accident, initial encounter) appended to 99308, 76705, 76604, and 99285 to represent how the patient was injured
• Y92.410 (Unspecified street and highway as the place of occurrence of the external cause) appended to 99308, 76705, 76604, and 99285 to represent the place the patient’s accident occurred.