ED Coding and Reimbursement Alert

Billing when the odds are against you

Many emergency department physicians and coders don't charge for ultrasounds - particularly those performed for thoracoabdominal trauma, one of the most common procedures in the ED. Often, this is because they receive pressure from payers to allow the radiology department to monopolize billing for such services. But don't be intimidated into assuming radiologists should receive all the reimbursement for the service - claim your deserved share with these expert tips.

Don't Back Down

While you may get denials from insurers prejudiced against ultrasounds performed in less traditional settings (such as the ED), you shouldn't stop billing for ultrasound services, says Steve Hoffenberg, MD, FACEP, president of CarePoint, an emergency physician group in Denver  and past chairman of the American College of Emergency Physicians (ACEP) section of emergency ultrasound. "The codes are the codes, and we meet the definitions. If we perform medically indicated tests, document them properly, perform the service as described, and retain an image for those codes where it's required, then we should be paid," he says.

Write It Properly or Forget It

"There are some issues with educating emergency physicians as to the proper selection of the codes, proper modifiers, and correct documentation - the service has to be documented as a formal interpretation," says Dennis Beck, MD, FACEP, CEO of Beacon Medical Services in Colorado and chairman of the ACEP reimbursement committee. "The payers would like to say that it's part of the physical examination, that it's not a separately identifiable service," so documentation is all the more crucial, he says.
 
Because the ultrasound is a separately identifiable service, the physician has to document clearly that he has met the requirements of what a specialist in the field would ordinarily do, Beck says. "You have to prove there's no technical reason to deny payment for this code," he says.

Report Tricky FAST Exams Fearlessly

Emergency physicians frequently evaluate abdominal trauma using a two-part ultrasound examination known as FAST - focused assessment by sonography for trauma. "The FAST exam is highly valued by emergency physicians and trauma surgeons," Hoffenberg says.
 
You have to be careful coding FAST exams, because "There is no FAST exam-specific code," Hoffenberg says, so don't expect to see "FAST exam" listed in CPT. "It's really a clinical approach, as opposed to a single ultrasound examination," Hoffenberg says. During this process, the physician first looks for fluid around the heart by performing a limited transthoracic echocardiography, and then looks for free fluid in the abdomen by performing a limited abdominal ultrasound.

Tip 1: Because of this dual service, you can report two separate CPT codes to describe the limited ultrasound exams composing the FAST exam: 93308 (Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; follow-up or limited study) and 76705 (Ultrasound, abdominal, B-scan and/or real-time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Tip 2: You should code the abdominal portion of the exam with 76705 (Ultrasound, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow up]).

Tip 3: For both portions of the FAST exam, use modifier -26 (Professional component) to indicate the professional component of the exam. Remember that you are required to retain the actual image in your documentation as well as your separately identifiable interpretive report.
 
Some physician groups that perform FAST exams only charge for the abdominal portion of the exam, because they either think they won't get paid for both parts or don't know to bill for both, Hoffenberg and Beck say. But billing for both is legitimate, Hoffenberg says: "This is work that is above and beyond that included in the E/M code - there's no ifs, ands, or buts about it. You should be billing it."