OIG Report- $2.4B in Unallowable Trauma Activation Charges

The Office of Inspector General (OIG) just released a critical audit revealing that 77% of trauma team activation claims submitted to Medicare between 2020 and 2022 did not meet federal requirements.

Key Findings:

• $2.4 billion in estimated unallowable charges.
• 107 out of 125 sampled claims failed to meet Medicare criteria.
• Common issues included:
  • No prehospital notification.
  • Trauma teams activated after patient arrival.
  • Patients not treated by trauma teams.
  • Incorrect coding and documentation.

These billing errors likely led to incorrect outlier payments and could distort future prospective payment system (PPS) rates.

Federal Billing Requirements: 

1. Prehospital Notification
   • The hospital must receive advance notice from prehospital caregivers (e.g., EMS) before the patient arrives.
   • This ensures the trauma team is mobilized based on field triage criteria.
   • Patients who arrive without notification (e.g., walk-ins or “drive-bys”) do not qualify.
2. Trauma Team Activation
   • The hospital must formally activate the trauma team in response to the prehospital notification.
   • Documentation must clearly show that activation occurred.
3. Activation Prior to Patient Arrival
   • The trauma team must be activated before the patient arrives at the hospital.
   • Activation upon or after arrival does not meet the requirement.
4. Treatment by the Trauma Team
   • The patient must be treated by members of the trauma team, not just seen in the emergency department.
   • Documentation should reflect trauma team involvement in care.
5. Reasonable and Necessary Care
   • The care provided must be medically necessary based on the patient’s condition.
   • For example, minor injuries that don’t require trauma-level care do not justify activation.
6. Correct Coding
   • Claims must include:
     • Revenue code 068X (with the correct subcategory for trauma level) OR G0390 (if patient is not admitted).
     • Type of Admission Code “05” (Trauma).
     • Correct NPI for the trauma-designated facility.

OIG Recommendations:

• CMS should revise guidance and increase education on trauma activation billing.
• CMS should work with MACs to identify similar instances of noncompliance occurring after this audit period.
• CMS should address the financial impact of these errors.

CMS did not concur with key recommendations, including their recommendation to address the estimated $2.4 billion in unallowable trauma team activation charges reported on hospitals’ cost reports and resulting incorrect outlier payments or working with MACs to address post audit occurrences. CMS said it would they would review existing guidance and assess the need for additional education.

This report underscores the need for clearer guidance, better documentation, and robust internal policies to ensure trauma activations are billed appropriately. We recommend conducting auditing and monitoring to validate compliance with trauma activation requirements, review internal policies and procedures to ensure they provide clear guidance and are up-to-date and provide education where indicated.

The OIG report can be found here: Hospitals Charged CMS for Trauma Team Activations That Did Not Comply With Federal Requirements, A-01-23-00500

The trauma activation guidelines are located in the Medicare Claims Processing Manual, Ch 4. Section160.1 -Critical Care Services: Medicare Claims Processing Manual