Trauma Codes/Coding


Winchester, VA
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Our surgeons are part of a "Trauma Team" and get called into the ER to care for trauma patients. We are debating how to appropriately bill for our surgeon's services. Would it be considered a "consult" and should bill 99241-99245 (depending on payer of course), or should we use ER codes 99281-99285, or something else? Someone mentioned using the critical care codes, but not all patients meet the qualifications of "critical care". Any advice would be greatly appreciated.
Heather, CPC :confused:
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I am also in the same boat. I have one surgeon in my group who is taking trauma call 6 days a month. I guess one of the biggest questions I have is that if a trauma patient comes in one night and a surgical procedure is done, the my physician who is following the patient over the next several days, am I able to code out for those days as subsequent days, or would it be considered post operative even though he was not the surgeon who operated and is not part of the group of doctors who performed the surgery. Any help with this question would be greatly appreciated, as I have to start coding out this week.
Last edited:
Milwaukee WI
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How your trauma surgeon bills will depend on several factors

Scenario 1 -
Patient presents to ER and trauma surgeon called for consult.
Surgeon evaluates and no surgical/procedural intervention required. Patient is discharged by ER physician.
Bill a consult IF you carrier allows it, otherwise bill ER visit

Scenario 2 -
Patient presents to ER and trauma surgeon called and minor procedure performed in ER.
Surgeon bills for the procedure. MAY bill for the E/M if there is documentation of a significant/separately identifiable service. (e.g. he did full workup to check for head trauma or serious internal injuries, but only had to suture a laceration on forearm).

Scenario 3 -
Patient presents to ER and trauma surgeon called - trauma surgeon determines major procedure required and admits patient for immediate surgery.
Surgeon will bill the initial hospital visit with -57 modifier for decision for surgery (OR ... if properly documented, might be billing using the critical care codes). Surgeon will also bill for the surgery performed. Any postoperative days in hospital or office visits following procedure are subject to the global surgical package (i.e. bundled); they are NOT billable - even if a different surgeon (but in the same practice as the one who operated) performs the postoperative visits.

There are some other possibilities, but this covers most of the cases our on-call surgeons see.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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My Doctors are also part of a trauma team, my question is, how do they get all of the elements needed for coding if they are using a trauma form rather than dictating an H&P?

Or does anybody have a good form they use that I could get lay out ideas from?

Thank You,

Tina Steffens, CPC:rolleyes: