Health Information Management

Get the facts on emergency department FAST exams

JustCoding News: Outpatient, December 14, 2011

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by Lori-Lynne A. Webb,CHDA, CCS-P, CCP, CPC, COBGC

Emergency and trauma medicine is ever-changing, as illustrated in the development of the focused abdominal sonography for trauma (FAST) exam. These exams are particularly effective because so many trauma patients have injuries that providers do not discover during the initial triage intake in the ED or trauma area.

Bedside ultrasounds have become more common because the equipment itself has become smaller and easier to use, and it produces high-quality images with this more compact size. This enhances the ability for emergency physicians to provide better care more quickly.

Although CPT® does not include a specific code for a FAST exam and coding authorities have not created a hard and fast definition of a FAST exam, coders currently report them using the following CPT codes:

  • 76705 (limited abdominal ultrasound)
  • 76775 (limited retroperitoneal ultrasound)

In some cases, the provider performs a transthoracic echocardiogram (CPT code 93308) at the same time as the FAST exam.

Know the purpose
In many trauma triage cases, physicians are trying to identify bleeding or free fluid in the abdominal, peritoneal, pericardial, or pleural space as quickly as possible. Unfortunately ultrasound—whether the healthcare professional performs it at the bedside or in the radiology department—is not 100% accurate in diagnosing or identifying all traumatic bleeding. However, a bedside ultrasound is more accurate than a standard chest x-ray for identifying hemothorax or pneumothorax in trauma patients.

Physicians perform most FAST exams in these four areas to try to locate the trauma. The physician should examine and document:

  • Peri-hepatic
  • Pericardial
  • Pelvic
  • Perisplenic

Due to the nature of traumatic injury, a computed tomography (CT) scan is superior to ultrasound, but physicians cannot perform these at the bedside.

A FAST exam is most useful for trauma patients who:

  • Are hemodynamically unstable (if hypotension is an unclear diagnosis)
  • Need an emergent bedside procedure
  • Require transfer from a small/community hospital to a large hospital or trauma center
  • Sustain a penetrating trauma with multiple wounds or unclear trajectory, especially with wounds in upper abdomen or lower chest (e.g., gunshot or deep stab wound)

In addition, healthcare professionals can observe and re-evaluate patients who are possibly intoxicated or have perhaps ingested drugs without exposing the patient to contrast or dye.

Understand documentation criteria
According to the CPT Manual, physicians must meet the following criteria for a coder or biller to report ultrasound services:

  • Interpretation. Facilities must maintain a written interpretation and report in the patient’s medical record. The report must describe the structures or organs studied and supply an interpretation of the findings. The report needs to clearly identify who performed the procedure and who interpreted the results. In some cases, a sonographer may perform the scan and then a physician interprets it.
  • Medical necessity. Physicians must document the medical necessity for the test.
  • Image retention. Facilities must permanently story appropriate image(s) of the relevant anatomy and pathology for future review. An image is now required for all procedures performed with an ultrasound.

Append appropriate modifiers for FAST exams
The ultrasound report also needs to fully describe whether the ultrasound exam was a complete or limited study or a repeat examination by the same physician, a repeat examination by a second physician, and/or a reduced level of service.

Modifiers are a necessary component for complete billing documentation. The following modifiers will paint the picture of the service you are reporting:

  • -26 (professional component only)
  • -TC (technical component only)
  • -52 (reduced services)
  • -59 (distinct procedural service)
  • -76 (repeat procedure by same physician)
  • -77 (repeat procedure by another physician)

When coding for the FAST ultrasound, it’s important to understand the differences between a limited exam and a complete exam.

CPT defines a complete exam as one in which the provider attempts to visualize and diagnostically evaluate all of the major structures within that anatomic region. CPT defines a limited exam as one in which the provider performs/documents less than the required elements of a complete exam. As a coder, you must review this information to determine whether the CPT Manual includes a code that describes the complete or limited exam, or whether a modifier is appropriate.

Take care when using modifier -52 (reduced service) when reporting a FAST exam. Review the documentation to determine whether the provider performed a complete exam, but due to the extent of the trauma or altered anatomy, the physician documented that he or she cannot visualize all structures. For this type of scenario, the physician attempted to perform a complete exam, so coders would report a complete exam code with the appropriate modifier.

Physician documentation of a FAST scenario

A 21-year-old male patient was involved in a motor vehicle accident with rollover. Patient is coherent alert and oriented x 3. Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated. The patient has equal and strong distal and proximal muscle group strength in all four extremities. The patient has negative Romberg and negative pronator drift. Patient is complaining of abdominal pain. Abdomen is firm, mild-to-moderate tenderness in the bilateral lower pelvic quadrants. There is some guarding. There is no organomegaly. Positive bowel sounds are auscultated throughout. BP 160/80, heart rate = 120, and patient states pain is a 9 of 10 on the pain scale.

I performed a FAST examination, limited ultrasound of all four body quadrants are negative for free fluid. All abdominal organs normal and do not show any signs of abnormal bleeding. The echo tech performed a limited transthoracic echo, and it was negative for any abnormalities as per my review.
I then re-examined the patient and determined patient to have a negative abdomen with multiple contusions and abdominal pain, status post motor vehicle collision. Patient will be discharged with instructions to return to the ED if pain increases or has nausea or vomiting. The patient is given a prescription for Vicodin for pain.

ECHO report: The LV was normal in size, wall thickness, and wall motion. The left ventricular systolic function was normal. Estimated EF was 65–69%. The RV was normal in size. The RV systolic function was normal. The left and right atria were normal in size. No intracardiac shunt was present. Trace MR and TR were present. The TR jet was insufficient to assess PA pressures. No pericardial effusion was noted. The transthoracic echocardiogram was interpreted as normal.

For this patient, the following CPT codes are appropriate:

  • 99283 for the evaluation and management services during the ED visit
  • 76705-26 and 93308-26 for the FAST exam

Editor’s note: Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, is an independent consultant and ICD-10 AHIMA accredited Trainer in Melba, ID. E-mail her at

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