Critical Care/Trauma Activation

Policy No: 118
Date of Origin: 04/01/2022
Section: Facility
Last Reviewed: 04/01/2023
Last Revised: 04/01/2023
Approved: 04/13/2023
Effective: 05/01/2023
Policy applies to: Group and Individual & Medicare Advantage

This policy applies to facility providers.

Critical Care – 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 are not limited to central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

Critical Care
Critical Care services can be considered for reimbursement when at least 30 minutes of face-to-face critical care is performed by a physician and/or qualified healthcare professional, billed with Current Procedural Terminology (CPT ®) 99291 and revenue code 045X, and/or documented in the medical records for the same date of service. CPT code 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 is not 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
Designated trauma centers/hospitals may bill for Trauma activation using revenue code 068X. Designated Trauma centers should not bill a trauma response activation level higher than their designated trauma center level.

Hospitals that provide less than 30 minutes of critical care when trauma activation occurs may report trauma activation with appropriate revenue code 068x but may not report HCPCS code G0390 and the service would be considered included in reimbursement for the visit.

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

CMS Medicare Claims Manual Chapter 4 Section 160.1

CMS Medicare Learning Network MM5438

CMS OPPS Visit Codes Frequently Asked Questions

Trauma System News Coding and Billing mistakes that reduce trauma center revenue

CMS Pub 100-04 Medicare Claims Processing

Pricing Codes Without RVUs

Medicare-Based Fee Effective Dates

Discarded Drugs and Biologicals