Are you accurately charging for trauma team activation? The OIG is watching

Revenue category code 068.X and HCPCS code G0390 allow trauma centers to cover the high costs of keeping a trauma team on standby—surgeons, ER physicians, anesthesiologists, nurses, etc.—and the incredibly complex, specialized care needed in some of the worst emergencies you’d ever want to imagine.

But with high reimbursement comes OIG scrutiny.

The recent OIG audit report “Hospitals Charged CMS for Trauma Team Activations That Did Not Comply With Federal Requirements” found that 107 of 125 sampled claims with trauma team activations did not meet Medicare requirements. 100 claims had unallowable trauma team activation charges totaling $728,468, and 7 sampled claims had coding errors, though the latter had no payment impact.

107 of 125 with errors = 77% of all claims submitted to Medicare with trauma team activations are incorrect, leading to some $2.4 billion in “unallowable expenses” per the OIG. It recommended CMS take the necessary steps to “address” (i.e., recoup) funds and install new compliance checkpoints.

To be compliant, hospitals must:

• Report charges using revenue category codes 068X with type of admission code 05. The 068X category includes revenue codes 0681, 0682, 0683, 0684, and 0689, with X generally representing the designation or verification level of the trauma center.
• Be a recognized trauma center, receive notification prior to the arrival of the patient, activate the team prior to patient arrival, and treat the patient. Care must be reasonable and necessary and accurately coded.

Note that if the hospital activates the trauma team but the patient is admitted to the hospital as an inpatient, the hospital will be paid via MS-DRG, with no additional payment made for trauma team activation. However, the hospital should still submit charges under revenue category 068X.

There are nuances, including what to do in the event of non-notification of the trauma team pre-patient arrival. See helpful article addressing that scenario below.

What were the errors the OIG found? The top 5 include:

1. The hospital activated the trauma team upon or after patient arrival (not before), or did not document time of activation (37 cases)
2. The hospital was not notified of trauma patient prior to patient arrival (23 cases)
3. The hospital did not provide the patient with treatment from the trauma team (16 cases)
4. The hospital submitted the claim with trauma activation for a patient who did not require care from the trauma team (15 cases)
5. The hospital did not activate the trauma team (9 cases)

Most interestingly, and utterly wild—CMS pushed back on most of the OIG’s recommendations, though the OIG maintains they are following guidance straight out of CMS’ own Medicare Claims Processing Manual.

You know billing rules are complex when CMS and the OIG don’t agree.

Given the dollars at stake here a compliance check is probably worth it.

References

• Read the full OIG report: https://oig.hhs.gov/documents/audit/11210/A-01-23-00500.pdf
• Helpful article on billing for trauma team activation without prehospital notification: https://trauma-news.com/2023/03/how-to-charge-for-trauma-activation-without-prehospital-notification/