Trauma team activation

This policy provides guidance for trauma activation billing and reimbursement when trauma services are rendered.

Applies to

  • All plans
  • Medicare plans follow Medicare coverage and billing rules

Definitions

Critical care

Critical care is a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition. Examples of vital organ system failure include, but aren’t limited to central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure.

Critical care services can be considered for reimbursement when at least 30 minutes of face-to-face critical care are performed by a physician and/or qualified healthcare professional, billed with CPT 99291 and revenue code 045X, and/or documented in the medical records for the same date of service.

CPT 99292 can be billed for each additional 30 minutes of critical care provided.

Critical care services less than 30 minutes should be billed as a visit, such as an Emergency Department visit, at the appropriate level. Critical care isn’t reimbursable if the member is discharged the same or next day with a discharge status code of 01 (discharged to home or self-care).

Trauma activation team

A trauma activation team is made up of key staff members who receive the member’s information for triage. Healthcare providers (i.e., facilities, hospitals, physicians and other qualified healthcare professionals) are expected to exercise independent medical judgement in providing care to members.

Billing

  • Use revenue code 068x in conjunction with FL 14, Type of Admission/Visit code 05. In the event of trauma activation, the facility must have received a prearrival notification from a prehospital caregiver, such as a paramedic or other emergency medical services provider.
  • If the member wasn’t assigned a prehospital notification revenue code, 068X shouldn’t be billed. However, the member may be classified as experiencing trauma on the UB-04, using FL 14, Type of Admission/Visit code 05 when identifying the member for follow-up purposes.
  • Non-designated trauma centers shouldn’t use FL 14, type 5 or 068X when billing for trauma services.

Reimbursement

Trauma activation is eligible for reimbursement when the following is met:

  • Billed on a UB04.
  • At least thirty (30) minutes of critical care is provided for the same date of service and documented in medical records.
  • Trauma team activation is documented in medical records and billed with HCPCS code G0390 and the appropriate 068X revenue code. CMS believes that trauma activation is a one-time occurrence in association with critical care services, and therefore, the health plan will only reimburse for one unit of G0390 per day.
  • Trauma center/hospital is licensed or designated by the state or local government authority or verified by the American College of Surgeons as a trauma facility and the facility is billing a trauma response activation level (revenue code) appropriate to their facility’s trauma level designation.

Revenue codes for trauma team activation

  • 0681: Trauma Response Level I
  • 0682: Trauma Response Level II
  • 0683: Trauma Response Level III
  • 0684: Trauma Response Level IV
  • 0689: Trauma Response Level Other Trauma Response

American College of Surgeons (ACS) criteria

In addition to appropriately billing trauma activation, there’s also trauma activation criteria set forth by the ACS. Apply the ACS criteria in the prehospital setting to identify trauma patients who would benefit most from the highest level of trauma activation.

The minimum criteria to activate the highest level of trauma activation is based on ACS 2022 updates to Resources for Optimal Care of the Injured Patient. It includes one or more of the following:

  • Confirmed blood pressure less than 90 mm hg at any time in adults, and age-specific hypotension in children
  • Gunshot wounds to the neck, chest or abdomen
  • Glasgow Coma Scale less than 9, with mechanism attributed to trauma
  • Transfer patients from another hospital who require ongoing blood transfusion
  • Patients intubated in the field and directly transported to a trauma center
  • Patients who have respiratory compromise or need an emergent airway
  • Transfer patients from another hospital with ongoing respiratory compromise (excludes patients intubated at another facility who are now stable from a respiratory standpoint)
  • Patients experiencing an emergency as determined by a physician