ED Coding and Reimbursement Alert

 Most FAST exam claims also need modifier 26

Patients who report to the ED with abdominal trauma often require a FAST exam so the physician can check for internal injuries. The exam is a two-part procedure, and you must code both portions of the exam correctly to garner complete payment.

Who needs it? The FAST exam (focused abdominal sonography for trauma) is -typically used on abdominal and trunk trauma patients, particularly blunt-trauma patients, to find out whether internal bleeding is occurring,- says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Chicago. The test -helps ED physicians figure out what they need to do for a patient -- and whether or not the patient needs to get to the OR quickly,- she says.

Code First FAST Portion With 93308

The first part of any FAST exam is a limited transthoracic echocardiography (ECG). During this procedure, the ED physician checks for the -presence or absence of pericardial fluid,- says Pamela Cline, RHIT, coder at Medical Accounts Services in Frederick, Md.

You should represent this procedure on your claim with code 93308 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study).
 Part II of the FAST exam is a limited abdominal study, which the physician conducts to check for fluid in the abdomen. For this portion of the exam, you should report 76705 (Ultrasound, abdominal, real-time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Attach Modifier 26 to Most FAST Exam Codes

 When coding for a FAST exam in the ED setting, Gilhooly says, you will almost always need help from modifier 26 (Professional component).
 
-This shows the insurer that you are coding for professional interpretation of the exam. In the facility setting, there is a presumption that the facility is responsible for all facility charges,- Gilhooly says.

Don't forget to attach modifier 26 to both 93308 and 76705 to show that you are coding only for the professional portions of both codes, Gilhooly says.

Prove FAST Exam Necessity With These Dx Codes

On your claim, you-ll need to prove medical necessity for FAST exams with the proper ICD-9 codes, or you could face a rejection. According to Eli Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass., these ICD-9 codes will prove medical necessity for a FAST exam with most payers:

- 789.0x -- Abdominal pain

- 786.5x -- Chest pain

- 922.1 -- Contusion of chest wall

- 922.2 -- Contusion of abdominal wall

- 458.9 -- Hypotension, unspecified.

 Best bet: Check with your payer for a list of ICD-9 codes that it will accept for FAST exams. -Many insurance companies -- especially Medicare carriers -- will not pay for FAST exam procedures if the diagnosis code is not on their list,- Cline says.

FAST Exam Typically Comes After E/M 

ED coders should also be on the lookout for separate evaluation and management services when the physician performs a FAST exam. During most FAST exam encounters, the ED physician performs an E/M first to evaluate the patient for further trauma.

-It is not typical for a patient to come to the ED with a scheduled appointment for a FAST exam,- Gilhooly says.

-These are high-energy injuries and potentially high-risk presentations, particularly in the setting of multiple trauma,- Berg says of FAST exam encounters.

Example: A 25-year-old male presents after an MVA (motor vehicle accident) involving a 40-mph impact into a tree. He is awake and alert but has bruising on his abdomen and is complaining of abdominal pain. His heart rate is 120. The physician is concerned about the possibility of an intra-abdominal injury.

As large-bore IVs are being placed, the ED physician performs a FAST exam, which confirms the presence of free intra-peritoneal fluid.

Ultimately, a CT scan confirms the presence of a small splenic parenchymal laceration. The ED physician reports 30 minutes of critical care time outside of separately billable procedures.

In this case, you would:

 - report 93308 for the thoracic portion of the FAST exam.

 - attach modifier 26 to 93308 to show you are only coding for the professional service.

 - report 76705 for the abdominal study.

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

 - report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care.

 - link 789.0x (Abdominal pain) to 93308, 76705 and 99291 to represent the patient's abdominal issues.

 - link 785.0 (Tachycardia, unspecified) to 93308, 76705 and 99291 to represent the patient's tachycardia.

 - link 865.03 (Injury to spleen with laceration extending into parenchyma) to 93308, 76705 and 99291 to represent the patient's spleen injury.

 - link E815.2 (Other motor vehicle traffic accident involving collision on the highway; motorcyclist) to 93308, 76705 and 99291 to represent the cause of the patient's injuries.

Depending on payer policy, you may need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to your E/M code to garner payment.

-Technically, CPT says you don't need modifier 25 for this claim, but many payers insist that you put modifier 25 on an E/M if it is separate [from the procedure],-   Gilhooly says.

Note: While this scenario involved a patient who needed critical care, not all FAST exam patients will need critical care. There may be instances in which the physician performs a standard ED E/M (99281-99285) before a FAST exam.

In these scenarios, be sure to choose the E/M level based on physician documentation.