Revenue Cycle Insider

Question: A patient presents to the emergency department (ED) with respiratory distress, hypotension, and a large thorax contusion after a metal barrel fell on them while they were working their job at a commercial construction building site. The ED physician evaluates the patient and decides they are too unstable for CT transport, so the physician places the patient on supplemental oxygen and performs a bedside extended focused assessment with sonography in trauma (eFAST) exam. The physician orders views of the pericardium, right upper quadrant (RUQ), left upper quadrant (LUQ), pelvis, and bilateral chest to evaluate the pleural spaces. The physician identifies pneumothorax in the right chest view. The cardiac, abdominal, left chest, and pelvic views are normal.

The physician archives each of the images and creates a separate, signed, written ultrasound report for each image, which includes the indication (blunt trauma/respiratory distress/hypotension), the specific views obtained, findings, and a final impression. Because the patient is unstable and has a positive eFAST, the patient is immediately treated with needle decompression using imaging guidance.

How should I code this encounter?

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Answer: For this claim, you’ll report the following:

• 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 ED evaluation and management (E/M) service
• 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 ED E/M service was significant and separately indefinable from the other services/procedures
• 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study) for the eFAST cardiac view
• 76705 (Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)) for the views of the RUQ, LUQ, and pelvis
• 76604 (Ultrasound, chest (includes mediastinum), real time with image documentation) for the chest ultrasound
• Modifier 26 (Professional component) appended to 93308, 76705, 76604 to show that you are only billing for your physician’s services, not the equipment they used
• 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) for the needle decompression

ICD-10-CM alert: If you code for each aspect of the patient’s condition — the injuries, the place of occurrence, the cause of the injuries, and the fact that the patient was working during the accident — you’re going to need quite a few ICD-10-CM codes. You should append the following diagnosis codes, in this order, to 99285, 93308, 76705, 76604, and 32555:

• S27.0XXA (Traumatic pneumothorax, initial encounter)
• S20.20XA (Contusion of thorax, unspecified, initial encounter)
• W20.8XXA (Other cause of strike by thrown, projected or falling object, initial encounter)
• Y92.61 (Building [any] under construction as the place of occurrence of the external cause)
• Y93.H3 (Activity, building and construction)
• Y99.0 (Civilian activity done for income or pay).

Angela Halasey, BS, CPC, CCS, Contributing Writer