Inpatient Facility Coding & Compliance Alert

Reader Question:

Not So FAST On Assigning Ultrasound Codes for Blunt Trauma

Question: What would be the CPT® code for ultrasounds done in ER for blunt chest and blunt abdominal trauma? Consider this procedure note for example:

Scope: rule out free intra-abdominal and pericardial fluid.

Impression: Hepatorenial space visualized, splenorenal space visualized, no free fluid noted, left kidney visualized, right kidney visualized, liver visualized, bladder visualized, heart visualized. Pericardial effusion absent. Wall motion present.

Any help is appreciated.

New Jersey Subscriber

Answer:

The procedure you describes consistent with FAST Exam or Focused Assessment with Sonography for Trauma exam. The FAST exam is actually 2 distinct diagnostic services looking for free fluid in the abdomen and examining the pericardium. You would report two codes when the documentation indicates performance of a FAST:

  • 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-Mode recording, when performed; follow-up or limited study)
  • 76705 (Ultrasound, abdominal, real time with image documentation, limited [e.g. single organ, quadrant, follow- up]).

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