Avoid trauma payment trouble by appropriately managing patient upgrades and downgrades

The U.S. Office of Inspector General (OIG) recently launched a review of Medicare payments for trauma claims.

One focus of the OIG review is trauma team activation (TTA) payments to hospitals that are not properly designated or verified trauma centers. While this is a genuine concern for the government, it is fairly easy for hospitals to avoid getting into trouble on this point.

(In case clarification is needed, if your hospital is not properly designated by your state or verified by the American College of Surgeons as a trauma center, you cannot bill for TTAs.)

In contrast, the major focus of the OIG review is actually a complex challenge for trauma centers: improper billing for TTAs that are not medically necessary.

Based on discussions I have had with centers that have been interviewed by the OIG, the key issue is patient upgrades and downgrades after activation. Hospitals that do not handle upgrades and downgrades correctly may end up billing for TTAs that were not medically necessary, exposing their organization to payer scrutiny.

In this article, I go over the basic concepts of upgrades and downgrades, explain the risks and benefits, and outline strategies for making sure your center is appropriately billing for TTAs when there is a change in the level of response.

Definitions, examples, benefits and risks

First, the basic concepts:

A trauma team activation is intended to be care that is medically necessary to meet the needs of an injured patient at risk of a life- or limb-threatening result. TTAs are based on activation criteria — typically MOIs, physiological indictors and the factors associated with higher risk for trauma patients. Most centers have several tiered levels of response — for example, full trauma activation, partial trauma activation, ED alert, etc.

After the trauma team is activated, if it turns out that the patient does not actually meet the hospital’s TTA criteria, the patient is downgraded to a lower response.

Conversely, after the trauma team is activated, if it turns out that the patient warrants the need for additional resources, the patient is upgraded to a higher response.

To help flesh out those definitions, here are a few example:

Now, let’s look at the implications of upgrades and downgrades for patients, trauma team members and trauma centers.

If a downgrade is inappropriate, the trauma center suffers because it will fail to be paid for a higher level of response that was medically necessary.

If a downgrade is appropriate, the main benefit is that the patient will not be billed for unnecessary care. But the other side of the coin is that your trauma team has been activated without cause. If there are too many downgrades over time, you risk overburdening your trauma team with unnecessary notifications.

And what about upgrades?

If an upgrade is appropriate, the benefit is that the patient receives the level of care necessary to treat his or her injuries. However, it is also true that this higher level of care has been delayed for a patient in need of rapid evaluation.

If an upgrade is inappropriate, it means the center is activating a team response when a simple surgical consult is needed. The end result is inappropriate billing.

Ways to manage the challenge of upgrades and downgrades

As I noted above, the government’s key concern seems to be patient upgrades and downgrades in the setting of trauma team activation. Specifically, the OIG is evaluating the practices of (a) charging patients for TTAs in the setting of downgrades and (b) upgrading patients to TTAs after workup is complete, which is essentially a surgical consult.

For hospital and trauma leaders, the overall action point is to make sure your trauma program is not engaging in these practices. Here are three ways to manage this challenge:

1. Evaluate over- and under-triage regularly and adjust activation criteria. Reducing your trauma program’s “incorrect triage” rate will reduce the need to adjust initial team responses up or down. You can use the Cribari Grid, the Need For Trauma Intervention (NFTI) metric or any system that works for your hospital. The key is to find an effective tool for assessing overtriage and undertriage and identifying opportunities for improvement.

Assess fall-outs within your program’s PI process and, if indicated, revise activation criteria to match the needs of your patient population more accurately. In particular, work with your surgical team to define when it is appropriate to upgrade and when a surgical consult is sufficient.

2. Support clinical decisions with documentation. Full documentation of upgrade/downgrade decisions is an important part of substantiating claims for TTA payment. When documenting a change in response level, be sure to reference your center’s activation criteria. If you are contacted by the OIG, they will want to see not just your trauma flow sheet documentation of an upgrade/downgrade decision, but the hospital policy by which that decision was made.

Remember, activation criteria specified in ACS standards (e.g., Standard 5.3) or state standards are minimums — your hospital can and should establish activation criteria that meet the needs of your trauma patient population. In addition, be sure that your hospital’s TTA policy delineates activation team roles and responsibilities, including expected response times. Documenting an adequate team response is essential to billing for TTAs.

3. Audit all activations for appropriate upgrade/downgrade decisions. The trauma PI coordinator or trauma program manager should review all patient upgrades and downgrades for appropriateness. Ask three questions: Did the patient meet criteria for activation on arrival? Did the patient’s condition change after arrival? Was the decision to upgrade/downgrade clearly documented?

There’s more to learn

Would you like to learn more about trauma patient upgrades and downgrades? I took a close look at this and other issues during a recent webinar:

OIG Trauma Payment Audits — What to Know and How to Prepare

(You can view the webinar on demand by clicking the above link.)

If you still have questions about upgrades and downgrades — or about any issue in trauma program leadership — I would be happy to share my thoughts. To set up a phone call, please feel free to contact me using the form below.

Angie Chisolm, MBA, BSN, RN, CFRN, TCRN is a nationally recognized expert in trauma program operational efficiency, coding and billing, site survey readiness and performance improvement. Angie is also president and managing partner of Optimal Healthcare Advisors.