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Billing for the Trauma Activation Code without Critical Care

Gerri Posted Tue 14th of June, 2011 12:19:48 PM

In all of the research I've done, CMS directs everyone to bill the trauma activation code along with the critical care code however; based on our facilites guidelines, a critical care code is not warranted every time trauma activation is necessary. I found some information regarding billing an ED visit with the trauma activation code vs, critical care and even though it will be bundled, you are still billing for the facility visit. Can anyone provide some insight on this?

Thanks !

SuperCoder Answered Wed 15th of June, 2011 14:59:28 PM

Designated/verified trauma centers should use a trauma response (activation) fee for patients with trauma. Patients with trauma undergo an intensive level of examination that requires hospitals to expend higher level of resources. Emergency department (ED) level of services does not cover this additional cost burden. With the UB revenue code 68x, hospitals have the opportunity to bill for these costs. Most reporting trauma centers have had considerable success with collecting these charges from PRIVATE payors but should not expect full payment from "self-pay" or insurers with whom the hospital has managed care Health Maintenance Organization (HMO) agreements.

You should still bill for ED services. Revenue code 45x will still be used to charge for the appropriate level of ED service. To incorporate revenue code 68x if you already bill for trauma activation under 45x, you need to "unbundle" your ED level of services and trauma response (activation) fee. The ED level of services will be billed according to a point system or using the ACEP method of assigning acuity, and the trauma activation component will be billed under the new revenue code 68x.

You can bill trauma and ED charges on the same bill. The trauma response (activation) charge should be placed on the patient hospital bill in addition to billing the ED level of service charge under revenue code 45x.

The trauma response (activation) fee levels should not differ on the basis of whether the patient was admitted or not. The trauma response (activation) charge is for the level of response a patient received regardless of whether the patient is admitted, is discharged, died, or is transferred.

You should always chart the fact that there was a prearrival notice from a medical third party, as well as the reason/criteria for activation, and maintain these details about the activation and response in the patient's medical record. Trauma centers need this documentation to dispute charges with payers and to track resource utilization.

Trauma centers may want to contact payer groups (insurers) directly and have open discussions about 68x charges if they are being newly implemented. Trauma programs can provide an executive summary introducing and explaining the trauma response (activation) fees and the services provided. The NFTC also suggests the following: providing an overview about the differences between ED and trauma charges, offering trauma center site visits to payer groups, using the "Community Standard" approach, etc. One hurdle is untying trauma care from existing discounted contracts with payors, called "carve-outs." Your trauma center is already likely to have several patient diagnoses that are billed full charges or patients are given a smaller discount than other HMO patients.

It is already determined that costs are higher for trauma critical care than for adult critical care and are paying more on the basis of their data. This should result in increased inpatient payment for 68x under the DRG for trauma patient care if the patient receives critical care 99291 on the same day of service. More importantly, correct billing by hospitals will allow CMS to collect more cost data, which can result in increased payments to trauma centers overall for trauma care or push the bill into higher outlier payments.
When CRITICAL CARE services associated with TRAUMA ACTIVATION:-

Beginning in CY 2007, CMS began paying differentially when critical care services were associated with trauma activation, identified by the inclusion of revenue code series 68x on the claim, on the same date of service as the critical care services. When trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x and the hospital provides at least 30 minutes of critical care so that CPT code 99291 is appropriately reported, the hospital may also bill one unit of HCPCS code G0390, Trauma response team activation associated with hospital critical care service, reported with revenue code 68x on the same date of service as CPT code 99291, and the hospital will receive an additional payment under APC 0618. Hospitals that provide less than 30 minutes of critical care when trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under revenue code 68x, may report a charge under 68x, but they may not report HCPCS code G0390. In this case, payment for the trauma response is packaged into payment for the other services provided to the patient in the encounter, including the visit that is reported.
To determine whether TRAUMA activation occurs or not? :-

To determine whether trauma activation occurs, providers are to follow the National Uniform Billing Committee (NUBC) guidelines related to the reporting of the trauma revenue codes in the 68x series. The guidelines are listed in the Medicare Claims Processing Manual, Pub 100-04, Chapter 25, §75.3. In summary, revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons. Different subcategory revenue codes are reported by designated Level 1-4 hospital trauma centers. Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.

When revenue code series 68x, trauma response, is billed in association with services other than critical care, payment for trauma activation is bundled into the other services provided on that day. Providers may refer to the Medicare Claims Processing Manual, Pub 100-04, Chapter 4, §160.1 for more information.

Prior to January 1, 2011, what services are included in CPT code 99291 (critical care, first 30-74 minutes) and should therefore not be billed separately? How should hospitals report ancillary services provided in conjunction with critical care beginning January 1, 2011?
Hospitals must follow the CPT instructions related to CPT code 99291. Any services that CPT indicates are included in the reporting of CPT code 99291 should not be billed separately by the hospital. Prior to January 1, 2011, CPT instructions indicated CPT code 99291 (Critical care, first 30-74 minutes) included a wide range of ancillary services such as electrocardiograms, chest X-rays and pulse oximetry. Therefore as stated in manual instruction, the specified ancillary services included in CPT's definition of critical care code 99291 prior to January 1, 2011, should not be billed separately.

Beginning January 1, 2011, CPT instructions indicate that for hospital reporting purposes, critical care codes do not include the specified ancillary services and therefore hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.

For CY 2011, CMS will continue to recognize the existing CPT codes for critical care services and will conditionally package payment for the ancillary services previously included in CPT's definition of critical care prior to CY 2011, when they are reported on the same date of service as critical care services. The payment status of the ancillary services will not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but during a different encounter. Payment for such services will not be conditionally packaged into the payment for critical care.

Gerri Posted Wed 15th of June, 2011 19:39:29 PM

Thank you so very much! Thus us EXACTLY what I was looking for.

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