Critical Care/Trauma Activation

Policy ID: Fac 118

Effective Date: January 01, 2027

Last Reviewed: June 15, 2026

Applies To: Migrated Commercial

This policy applies to facility providers.

Definitions

Code/Term

Code Description/Term Definition

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.

Current Procedural Terminology (CPT^®)

A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).

Evaluation and Management (E&M) Services

Services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified healthcare professional reporting the service.

Healthcare Common Procedure Coding System (HCPCS) Level II

A standardized coding system that is used primarily to identify services that include, but are not limited to drugs and biologicals, ambulance services, durable medical equipment, prosthetics, orthotics and other services not represented in the HCPCS Level I (CPT).

Revenue Codes (Rev Codes)

Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Policy Statement

Critical Care

Critical Care services can be considered for reimbursement when a minimum of 30 minutes of face-to-face critical care services are performed by a physician and/or qualified healthcare professional, billed with CPT code 99291 and revenue code 045X and 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 services provided.

Critical care services less than 30 minutes should be billed with an appropriate evaluation and management (E&M) CPT code, such as an Emergency Department visit.

Time increments for Critical Care Codes

Commercial

Less than 30 minutes – appropriate E&M code

30-74 minutes - 99291

75-104 minutes – 99291, 99292x1

105-134 minutes – 99291, 99292x2

135-164 minutes – 99291, 99292x3

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) unless rare circumstances occur and are supported in the medical records. For example, a patient who requires cardioversion and improves enough to be discharged home the next day. See additional examples of critical care services, according to the American College of Emergency Physicians (ACEP) guidelines below.

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 HCPCS code G0390 should not be reported.

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 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

References

Cross References

Adm 113 - Pricing Codes Without RVUs
Adm 114 - Medicare-Based Fee Effective Dates
Adm 129 – Correct Coding Guidelines

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

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