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Part 3: Trauma Activation and the Emergency Department Revenue Cycle

Disclaimer: This is part three in our three-part series on the emergency department revenue cycle. This information was drawn from the webinar Financial Best Practices for the Emergency Services Revenue Cycle. It was current at the time of its publishing and presentation via the web and is designed to provide accurate information in regard to the subject matter covered. It is not intended to take the place of either the written policies or regulations. We encourage you to review the specific regulations and other interpretive materials as necessary.

Based on a webinar by Bill Malm, an experienced member of our charge capture team and ED professional, we have created three resources to help guide your emergency department revenue cycle:

Let’s get into part three.

Trauma Activation

With the ever-increasing attention to price transparency as a backdrop, charges for trauma activation — which can be quite expensive — are increasingly subject to public scrutiny and questioning. (This article in Vox is a good example.) Every hospital needs to know its trauma activation policies and protocols, but as you will see, it’s also a topic well worth exploring from a revenue cycle perspective.

Every hospital is assigned a trauma level sub-code from 4 to 1, with 1 being the highest level of trauma capability – there are usually only two or three such facilities per state. These numbers replace the x in revenue code series 68x. The final digit is designated by the state or local government authority authorized to do so, and these assignments are verified by the American College of Surgeons.

Requirements for Trauma Activation Coding

The main requirement for use of these codes is prehospital notification. Here is the language in the regulation created by the National Uniform Billing Committee (NUBC) for reporting of the trauma revenue codes in the 68x series. The guidelines are listed in the Medicare Claims Processing Manual, Chapter 25, §75.4:

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.

We’ve bolded the statement about prehospital notification, as this is a must for a trauma activation. Our auditors sometimes see activations with patients who have walked into the ER on their own power, or activations documented in peculiar circumstances. For example, we’ve seen activations take place in an elevator on the way to surgery.

This doesn’t mean you can’t charge for trauma activations without the prehospital notification requirement, it simply means that you don’t use HCPCS G0390 with revenue code 068x. Instead, you’ll need to apply a 068x charge to an uncoded line item — no HCPCS code. Then code the emergency visit as you normally would using a point system for the facility resources.

Here are other requirements for trauma activation with prehospital notification and critical care:

  • Trauma activation for Medicare has to meet the criteria based on CMS guidelines.
  • The code used for trauma activation with critical care is G0390. Not all payors take this code, but Medicare does.
  • There needs to be at least 31 minutes of facility-based critical care in order to qualify for the G0390. This means face-to-face care with resources belonging to the facility, not the physician. While it may not match exactly with physician timing, it does include face-to-face time with nursing and ancillary care.
  • You’ll want to use revenue code 068x, where x is equal to the level of trauma certification for your facility.
  • Finally, charges must reflect resources the facility consumed providing care.

Trauma Activation for Private Payors

Most payors follow Medicare activation requirements. One consistent requirement beyond Medicare’s requirements for private payors is to use the American College of Surgeons standard as documented in the Resources for the Optimal Care of the Injured Patient (2006). This document specifies that the minimum criteria for the definition of a major trauma patient include one of the following (documented) conditions:

  • Confirmed systolic blood pressure of <90mmHg in adults and age-specific hypotension in children
  • Respiratory compromise, obstruction or intubation
  • Use of blood products to maintain vital signs in patients transferred from other hospitals
  • Discretion of the emergency physician
  • Gunshot wounds to abdomen, neck, or chest
  • Glasgow Coma Score less than 8 with mechanism attributed to trauma

The Glasgow score must be determined as a result of the trauma concern. For example, a patient with chronic neurologic or mentation issues can have a low GCS, however, it was not due to the trauma concern, therefore would not count for the last point.


Trauma activation from a revenue cycle perspective has always been an important element of the revenue cycle process for emergency departments. And knowing how to handle the different types of trauma activations will be essential in contracting with payors, and ultimately, in price transparency as we move forward.

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