Question

What are the new Trauma Codes, Form Locator (FL) 19, Type 5 and Revenue Code, 68x "G" 0390 and APC 0618 and how should they be implemented?

Answer: 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.

FL 19, Type 5 is the new admission type for trauma patients treated at a trauma center/hospital that is verified by the American College of Surgeons (ACS) or designated by state/local authority. 68x is the assigned UB code for finance/billing departments to bill for trauma activation fees.

Nonverified trauma centers cannot use the new codes. However, this is an incentive to get ACS verification or state/local designation.

You will not be able to charge the patient, using the 68x code, if a patient is driven to the hospital by a family member or walked into the trauma center. You will still be able to use the FL 19, Type 5 to ID the patient as a trauma patient. If there are significant numbers of these patients, we will consider a petition to the National Uniform Billing Committee (NUBC) to alter this definition.

You can use the 68x code for hospital transfers. You will be able to use the 68x code as long as there was some type of organized response rendered and the patient met criteria for trauma triage or interhospital transfer in the early phases of care.

HCPCS (CPT) and APC codes need to be used with the trauma activation charges (68x). In December 2006, CMS (Medicare) assigned a new "G" code 0390 as well as APC 0618 to Trauma Response 68x. In a somewhat-confusing manner, they have limited payments of nearly $500 per activation to only those trauma responses associated with a HOSPITAL HCPCS critical care code, 99291, on the same day of service. This means that hospitals will get Medicare payments only for full trauma team patients who receive 30 minutes of critical care services or more.

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 and be tied to FL 19, Type 5 "trauma center" patients.

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.

UB 68x is still being studied by CMS, so you will not receive payment for UB 68x unless it is associated with 99291, critical care. However, they have 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.

If insurers refuse to pay the trauma surcharge, hospitals should follow their standard procedures for collection/billing. For example, standard appeal letters should be developed to be accompanied by copies of ACS/local-state field triage, or interhospital transfer criteria, along with the pertinent medical records showing that the patient received trauma services within times appropriate for the level of trauma center and patient condition.

The development of a group similar to the trauma program Performance Improvement committee is encouraged for finance performance improvement so that participants in trauma billing and collections receive regular reports and feedback about the program's success in achieving payment for all trauma-specific codes.