Check for High-Level E/M Before Coding FAST Exams
Published on Mon Oct 26, 2009
Documentation could even support critical care. Given that most patients requiring focused assessment by sonography for trauma (FAST) exams have suffered extensive and traumatic injuries, don't be surprised if you see high-level ED E/Ms on FAST exam encounters. You need to be able to recognize, however, that some cases fall short of the required elements. A level-five E/M is a possibility for many FAST exam patients, so keep your eyes peeled for encounter details that could help justify 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...). In fact, FAST exam patients might even need critical care before the FAST exam in certain situations, explains Greer Contreras, CPC, senior director of coding [...]
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