ED Coding and Reimbursement Alert

When your physician performs a FAST (focused assessment by sonography for trauma) examination, be sure to go through the notes slowly or you could miss one of the three common codes.

FAST exam patients are almost always in some physical trauma, which requires a high-level E/M service; once the physician makes the decision, she'll perform a pair of procedures to complete the FAST exam.

Use this guide to correct coding so you'll be quick on the draw when coding for trauma patients requiring FAST exams in your ED.

The high acuity of the ED setting is part of the reason that ED physicians perform their fair share of FAST exams; "Common presentations associated with internal bleeding include blunt trauma such as MVAs [motor vehicle accidents] and significant falls," states Eli Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass.

During a FAST exam, the emergency physician is looking for a collection of fluid in the chest, abdomen, and pelvis, explains Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service Inc. in California.

According to Jennifer K. Curry, clinical manager for the department of emergency medicine for UMDNJ-Robert Wood Johnson Medical School in New Brunswick, N.J., FAST exam candidates could include patients who have:

• suffered blunt trauma to the trunk/abdomen

• hypotension with abdominal pain

• severe abdominal pain radiating to the back (to rule out aortic dissection)

• abdominal pain with recent cardiac or vascular catheterization with access through the inguinal vascular system (to rule out retro peritoneal bleed).

There are two steps to any FAST exam, confirms Curry.

Step 1: The physician performs a limited transthoracic echocardiography (ECG) to check for pericardial fluid, which you should code with 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study), says Berg.

Step 2: The physician performs a limited abdominal ultrasound to check for abdominal fluid, says Todd Thomas, CPC, CCS-P, president of ERcoder Inc. in Edmond, Ok.; report this part of the exam with 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Consider this example of a possible FAST exam op note from Thomas:

Performed bedside limited US for blunt torso trauma. Pericardial space, right/left upper quadrants and pelvis were visualized: no obvious pericardial effusion or hemoperitoneum, or hypoechoic areas within the liver/splenic parenchyma that were seen. Interpretation: Normal FAST exam.

For this encounter, you'd report 76705 and 93308 for the FAST exam. Remember to append modifier 26 (Professional component) to both codes, reminds Contreras.

Why? Modifier 26 shows the insurer that you are not billing for the equipment, only your physician's services.