[traumanurses] Re: activation fees

["Leiding, Lisa" <Lisa.Leiding@stvin.org>]

Bev,

 

They have to meet pre-hospital activation criteria - which is published in their protocols and approved at our regional trauma advisory. .

They may get activated in the ED or by EMS or they might not get "activated at all".

 

For example we have a patient who arrives with bilateral femur fractures. Our EMS criteria states ">2 long bone fractures". So EMS decides not to call the trauma activation because "the patient is stable". The ED MD gets in the room and doesn't call it either - "because he feels he can handle it". Yet the charge nurses and the ED nurses get radiology to the bedside, and the trauma blood from the lab and they mobilize the second nurse to help with getting the patient undressed, examined and traction put on etc... So the patient gets the team even though it wasn't systematically paged in. It uses all of my basic in house team. As a level III we have the ED MD, the lab, radiology, and two nurses as our basic team. The ED MD walks out of the room and asks to have the surgeon / orthopod come to the ED. My surgeons - even if it is at night live max 15 - 20 minutes away so even at night they are usually in within 30 minutes. We take the patient to CT and then we either take the patient to OR or transfer if we find more fractures.

 

The whole idea is to spread charges out across most of the "qualifying patient population" - so the qualifying patients must meet all the below are:

 

patients who are admitted to the hospital,

registry patients, 

have injury related E-codes,

ICD-9 codes as defined by the state and hospitals,

transferred in / out or died in ED after active resucitation,

or activation of the trauma team regardless of patient disposition. (death, home, admission, transfer)

 

The activation fees (UB92 requirements) have 2 additional criteria -

there must be a documented pre-hospital report and

the patient must meet pre-hospital trauma activation criteria that is published and approved through the ReTrAC (regional trauma advisory council) for us to bill an activation fee.

 

I am pretty hard on the documentation - if the nurses don't chart the pre-hospital report I make them put in an addendum to the chart and if they don't then I do not charge and I turn it over to the ED Director. I put the prehospital report on our new trauma flowsheet - which I tried to send out on the list yesterday - but didn't see it come up. If you want it I can send that to you on your email.

 

The team documentation has been my biggest thorn. The nurses will write in the ED staff - but not the ancillary team member names or arrival times. So I am working with our hospital's QI / QM team and we are going to have some better documentation or it will kill me. We are currently losing our ability to charge activation fees because of this. So I have to take it back to the nurses - if they refuse to track down the information and chart it on the trauma sheet then I take it to the ED director and do an incident report. We are going to track the $ loss per nurse and that should make our union really happy- especially right before re-designation!

 

At this time we basically have 2 levels of criteria and are working on a third level. All of the ACS field triage criteria are in the two levels at this time. We are working on bringing some of the consultation criteria up into a Level II activation and some of the STAT criteria down into the level II activation criteria. Our STAT criteria will get the whole shebang paged out. The level II will get the in-house team paged and the consultation criteria will get the basic ED team / work-up with a trauma consult. Right now it is either the whole shebang or it is the ED team (lab, radiology, ED MD, ED nurse 1 or 2 depending on the needs of the patient).

 

ISS Scoring

ISS scoring is done on the qualifying patients who meet activation criteria. So we determine qualifying patients first, then activation fee criteria. If they meet both of those criteria then we do the ISS score before the 5 day window for billing. 

 

In March 2003 when we started this new process it looked like this:

   47 registry patients, 25 total qualifying trauma registry patients, 20 who were charged activation fees.

 

In April 2003 it looked like:

   36 registry patients, 26 total qualifying trauma registry patients, 15 who were charged activation fees.

 

I go up daily and do rounds on the patients. I get the listing of injuries from the MD dication, radiology reports or op reports - as far as internal injuries. If there are lacerations / abrasions etc.. I go look at those to make sure that it's not really an avulsion or degloving or burn etc... We have to bill by the 5th day after discharge. The discharge dicatation has to be in the chart before that. The biggest area I always have problems with is the spleen  / liver lac grades. They don't chart it - so I have to go prompt them to give me a grade in their progress note.My neurosurgeons are pretty good about documenting the size of the SDH or SAH.

 

We have a trauma patient who has been here in ICU about 2 weeks. I have the diagnoses - now it is just a matter of watching for any complications. But I will double check the ISS on the 2nd or 3rd day after discharge. If we have a missed injury around here I usually hear about it within 24 to 48 hours depending on my work schedule - the surgeons usually come to me with problems with other MD's or diagnosis issues, etc  - I feel like I have finally graduated to motherhood.

 

My ultimate goal will be to have palm pilot registry that I can take to the floor - input data and then come downstairs and download.

 

We also have new billing requirements here in this state. So ... the patients either are "qualifying patients" or not. So if they meet the "qualifying criteria" then I have to figure out who the MD's are that are seeing that patient and which one of those MD's are "qualifying" to bill non-discounted. Some patients the ED MDs can bill non-discounted and other ED MDs can not - so I have been tracking that as well. My neuro surgeons require a letter to accompany the bill stating that X patient meets the criteria for a non-discounted bill. I then put in the patient's name, E codes, defer the ICD 9 codes to the billing form, the team response, and pre-hospital report. Sign my name. Our third party payers are really new to this - so they dont' know what they want for verification yet.

 

"qualifying patients" get a non-discounted bill

"activation fees" go to qualifying patients who also meet UB92 code requirements - prehospital report and documented team response.

 

Who isn't getting charged are people with injuries that don't get a team response. For example: isolated colles fractures from our ski basin are being tracked in the registry for outreach - but they don't meet EMS criteria and they probably are not admitted.

 

Does that answer your questions?

Lisa Mclaughlin, RN

Trauma Coordinator

St. Vincent Hospital

Santa Fe, NM

505-820-5708

 

 

 

 -----Original Message-----
From: Long, Bev [mailto:Bev.Long@dhha.org]
Sent: Friday, July 11, 2003 2:48 PM
To: traumanurses@mailman.listserve.com
Subject: [traumanurses] Re: activation fees

Lisa,  Could you clarify for me please.

 

1.  Are you saying you are charging for activations on patients who were not actually activations, but met ISS criteria?

2.  How do you calculate ISS at time of billing?  We do not get our ISS scores until the charts are abstracted.

 

Thanks.

________________________________________
Bev Long
Service Line Administrator for Trauma/CC/EMS
Denver Health Medical Center
777  Bannock, MC 0206
Denver, CO 80204
(303) 436-6586
bev.long@dhha.org
________________________________________

-----Original Message-----
From: Leiding, Lisa [mailto:Lisa.Leiding@stvin.org]
Sent: Friday, July 11, 2003 6:36 AM
To: 'traumanurses@mailman.listserve.com'
Subject: [traumanurses] Re: activation fees

Jill,

In our state activation fees can only be charged by designated hospitals. HOWEVER - one of the things I learned in the past year as we re-did our finances here...no one ever negotiated our activation fees with the third party payers...so the third party payers never paid us it was written off the top of the bill - so it actually looked like we were discounting more if you were a trauma patient. Go that one fixed ASAP.

Bishops and Associates helped us reconfigure our activation fee thought process this year. We too looked at only charging the activation fees on those that had full team activation - however almost all of our patients had the same team response - it was just about time. Did the surgeon come in 30 minutes or were they in house and came to the ED in 10 minutes or did they make a deal with our ED MD's to come after CT etc.... We are a single community hospital with about 5 - 7 level I activations a month that are "COME NOW" response.

When we looked at the services that we have to have on a 24 hour a day basis - it made no financial sense to do activation fees on only 5 to 7 patients a month. Those 5 to 7 patients can not "pay" for a trauma program. So with the help we looked at basing activations on the ISS scoring of everyone that meets our pre-hospital level I and level II and consultation criteria.

The only people thrown out of this mix then were those that we don't have a documented pre-hospital report on. Which a month ago was almost all of my 50 patients who decided to bring their paralyzed, their shot, their stabbed, and their "my truck ran me over" by POV.

Bishops and Associates will come to your hospital and do the presentation for the administration and physicians. Our state received a grant to bring them to the designated centers in New Mexico to help figure out how we can comply with the new financial portion of our regulations. I am sure that there are others out there who will do the same thing - I am just not familiar with them.

Lisa McLaughlin
Santa Fe, NM

-----Original Message-----
From: Jill_Buttry@deaconess.com [mailto:Jill_Buttry@deaconess.com]
Sent: Thursday, July 10, 2003 2:33 PM
To: TraumaNurses@TraumaNurseSoc.org
Cc: connie@traumacare.com
Subject: [traumanurses] activation fees

I would like to have clarification on a couple of issues below please:
*       Hospitals cannot charge Trauma Activation fees until they are
verified/designated as a Trauma Center - correct?
*       Do you charge activation fees even if it was considered an over or
undertriage?

Thank you for your input.

Jill Buttry, RN, MSN, CNS
Deaconess Trauma Program Manager
jill_buttry@deaconess.com
www.deaconess.com/trauma
Office: (812)450-3867
Fax: (812) 450-5049

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