Ontario Health Insurance Plan

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Trauma Premium (E420)

Category: Anaesthesia, Critical Care, Emergency Medicine, Surgeons and Surgical Assistants
Date of publication: November 3, 2022

Claims Tips: For claims payment purposes, the trauma premium and associated services must be submitted on the same claim record. The inclusion of medical records that support payment requirements with the submitted claim is always helpful to ensure accurate adjudication and prompt payment of complex procedures.

E420 is eligible for payment when payment rules are met

A trauma patient with an Injury Severity Score (ISS) listed on the medical record of:

>12 when the patient is less than 16 years of age
>15 when the patient is 16 years of age or older

The service is provided on the day of trauma, or within 24 hours of the trauma

Common claims Issues

Errors in calculation of ISS score
Claiming E420 > 24 hours following the trauma
Lack of documentation to support claim/assist in adjudication (example, date of trauma; ISS score; description of injuries that support ISS score calculation)

E420 applies to the following services when payment rules are met

Services listed in the following Sections of the Schedule of Benefits:

Consultations and Visits (Section A of the Schedule)
Obstetrics (Section K of the Schedule)
Surgical Procedures (Section M through Z of the Schedule)

Basic and time units provided by an anaesthesiologist or a surgical assistant.
The following resuscitative services: G391, G395, G521, G522, and G523.

E420 is not applicable to:

Any service, including diagnostic services, not listed above.
Other premium codes such as special visit premiums and after-hours premiums.

Payment information

The value of the premium is 50% of the fee payable for the eligible service(s) provided.

Calculation of an Injury Severity Score

The Injury Severity Score (ISS) is used to describe severity of injury in a trauma patient. Injuries are categorized in one of 6 body areas and scored according to the Abbreviated Injury Scale (AIS). The ISS score is the sum of the squares of the highest AIS score in each of three different areas. Table 1, Parts 1 and 2, provide examples of AIS scoring for a range of injuries.

While many online calculators include the ISS, these may lead to inaccurate calculations if accurate AIS scores are not used to generate ISS data. Definitive resources to inform AIS scoring, and ISS calculation are available on the Association for the Advancement of Automotive Medicine (AAAM) website.

Six body areas

Head or neck injuries include injury to the brain or cervical spine, skull or cervical spine fractures and asphyxia/suffocation.
Facial injuries include those involving mouth, ears, nose and facial bones.
Chest injuries include all lesions to internal organs, drowning and inhalation injury. Chest injuries also include those to the diaphragm, rib cage, and thoracic spine.
Abdominal or pelvic contents injuries include all lesions to internal organs. Lumbar spine lesions are included in the abdominal or pelvic region.
Extremities or pelvic girdle injuries include sprains, fractures, dislocations and amputations.
External and other trauma injuries include lacerations, contusions, abrasions, and burns, independent of their location on the body surface, except amputation burns that are assigned to the appropriate body region. Other traumatic events assigned to this ISS body region are electrical injury, frostbite, hypothermia and whole body (explosion-type) injury.

Table 1 - Part 1: Examples of the AIS Score

AIS Score	Head/Neck (includes C-Spine)	Face (includes Eye/Ear)	Chest (includes T-Spine)
Minor	Superficial scalp laceration	Corneal laceration Tympanic membrane rupture Zygoma fracture, non-comminuted Tooth fracture	Abrasions/contusions/minor lacerations of thorax Rib fracture – 1 rib Cardiac contusion – minor T-Spinous or transverse process fracture
Moderate	Scalp laceration, >10cm + into subcutaneous tissue Skull fracture, vault, closed Epidural or subdural hematoma <0.6 cm Subarachnoid hemorrhage, no LOC or LOC <=6 hours	Facial nerve laceration, unilateral LeFort I or LeFort II fracture	Rib fractures – 2 ribs Brachiocephalic vein – minor laceration Lung contusion*, unilateral/minor Sternal fracture Pneumothorax T-Vertebral compression >20% anterior height loss/burst
Severe but not life-threatening	Total scalp loss Skull fracture, vault, open with intact dura or depressed <= 2cm Subarachnoid hemorrhage, LOC >6 hours Odontoid fracture	Facial nerve laceration, bilateral LeFort III or panfacial fracture Major laceration jugular vein; blood loss > 20% by volume	External carotid artery, major transection; blood loss >20% Lung contusion*, bilateral/minor or unilateral/major Rib fractures >=3 ribs or with flail Hemothorax
Life-threatening but survival likely	Skull fracture, open with torn dura or depressed >2cm Epidural or subdural hematoma 0.6-1 cm thick, <= 30cc Incomplete spinal cord Injury	Facial fracture with blood loss > 20% by volume	Cardiac contusion, major Hemothorax, major blood loss >20% by volume Major pneumothorax > 50% collapse of lung Open/sucking chest wound Diaphragm rupture with herniation Lung contusion*, bilateral + major
Critical with uncertain survival	Epidural or subdural hematoma >30 cc Complete spinal cord injury		Tension pneumothorax Bilateral flail chest Major rupture thoracic aorta

* Lung contusion only applicable with imaging confirmation.

Table 1 - Part 2: Examples of AIS Score

AIS Score	Abdominal/Pelvic Contents (includes L-Spine)	Extremities/Pelvic Girdle	External
Minor	Abrasions/contusions/minor lacerations of abdominal wall Superficial or minor abdominal penetrating injury	Abrasions/contusions/minor lacerations of extremities/pelvic girdle Scalp laceration, superficial, superficial Joint capsule rupture/tear Carpal dislocation	First degree burn 2nd degree burn <10%
Moderate	Simple liver capsular tear, <= 3cm parenchymal depth Small or large bowel contusion or partial thickness injury Minor kidney hematoma, subcapsular, nonexpanding Chance fracture, lumbar spine, no neuro deficit	Most closed fractures and dislocations (some may = 1) Median nerve laceration Pelvic ring fracture, isolated, stable, closed	2^nd or 3^rd degree burn 10-19% Degloving injury arm/forearm Electrical injury
Severe but not life-threatening	Liver laceration, >3cm parenchymal depth Small or large bowel perforation or full thickness laceration Penetrating injury with blood loss >20% Major kidney hematoma Bladder rupture	Most open fractures Complete brachial plexus injury Below elbow or below knee amputations Compartment syndrome with muscle loss	2^nd or 3^rd degree burn 20-29% Near drowning, without neurological deficit Electrical injury with muscle necrosis
Life-threatening but survival likely	Small or large bowel massive injury, large areas of devitalization, devascularization Massive/complex bladder injury	Above elbow or above knee amputations Femoral artery transection Pelvic fracture, open or totally unstable or with moderate pelvic hematoma	2^nd or 3^rd degree burn 30-39% Near drowning, with neurological deficit
Critical with uncertain survival	Renal hilum avulsion, Shattered kidneys Transection abdominal aorta	Bilateral above knee amputations Pelvic fracture with blood loss >20%	2^nd or 3^rd degree burn 40-89% Electrical injury with documented cardiac arrest

AIS Score

Abdominal/Pelvic Contents (includes L-Spine)

Extremities/Pelvic Girdle

External

Minor

Abrasions/contusions/minor lacerations of abdominal wall

Superficial or minor abdominal penetrating injury

Abrasions/contusions/minor lacerations of extremities/pelvic girdle

Scalp laceration, superficial, superficial

Joint capsule rupture/tear

Carpal dislocation

First degree burn

2nd degree burn <10%

Moderate

Simple liver capsular tear, <= 3cm parenchymal depth

Small or large bowel contusion or partial thickness injury

Minor kidney hematoma, subcapsular, nonexpanding

Chance fracture, lumbar spine, no neuro deficit

Most closed fractures and dislocations (some may = 1)

Median nerve laceration

Pelvic ring fracture, isolated, stable, closed

2^nd or 3^rd degree burn 10-19%

Degloving injury arm/forearm

Electrical injury

Severe but
not life-threatening

Liver laceration, >3cm parenchymal depth

Small or large bowel perforation or full thickness laceration

Penetrating injury with blood loss >20%

Major kidney hematoma

Bladder rupture

Most open fractures

Complete brachial plexus injury

Below elbow or below knee amputations

Compartment syndrome with muscle loss

2^nd or 3^rd degree burn 20-29%

Near drowning, without neurological deficit

Electrical injury with muscle necrosis

Life-threatening but survival likely

Small or large bowel massive injury, large areas of devitalization, devascularization

Massive/complex bladder injury

Above elbow or above knee amputations

Femoral artery transection

Pelvic fracture, open or totally unstable or with moderate pelvic hematoma

2^nd or 3^rd degree burn 30-39%

Near drowning, with neurological deficit

Critical with uncertain survival

Renal hilum avulsion, Shattered kidneys

Transection abdominal aorta

Bilateral above knee amputations

Pelvic fracture with blood loss >20%

2^nd or 3^rd degree burn 40-89%

Electrical injury with documented cardiac arrest

Reference: AAAM, The Abbreviated Injury Scale Dictionary, 2015 revision.

Examples

Example 1: Adult patient involved in a gas explosion presents with:

Injury	Score	Body area	Highest score/area (top 3)
Abrasions right hand	1	External	✔
Ruptured tympanic membrane	1	Head/neck
Rib fracture, 5th, left	1	Chest
Small bowel contusion	2	Abdomen	✔
Femur fracture, left (open)	3	Extremity	✔
Tibial fracture, right (closed)	2	Extremity

ISS = 1² + 2² + 3² = 14
This patient would not meet the criteria for the use of the E420 code. Note that only one of the scores associated with the femoral and tibial fractures may be counted in calculating the ISS as these both represent the extremity body area.

Example 2: Adult patient from motor vehicle-versus-pedestrian collision presents with:

Injury	Score	Body area	Highest score/area (top 3)
Epidural hematoma <0.6 cm thick	2	Head/neck
LeFort III fracture	3	Face	✔
Rib fracture, 6/7/8, left side with flail	3	Chest	✔
Small bowel contusion	2	Abdomen
Tibial fracture, open	3	Extremity	✔

ISS = 3² + 3² + 3² = 27

This patient would meet the criteria for the use of the E420 code. Any applicable services provided on the same day as the trauma or within 24 hours of the injury would qualify for this premium. If two surgeons are required to provide surgical reconstruction of this patient’s injuries, both surgeons may claim primary surgical fee codes for the procedures that they perform components of.

The patient described above is admitted to the intensive care unit following initial emergency stabilization. 72 hours later, the patient is brought to the operating room for additional procedures related to the trauma. Is the E420 premium applicable at this stage?

No, the E420 trauma premium is only applicable within 24 hours of the initial trauma.

Example 3: Adult patient injured in workplace presents with:

Injury	Score	Body area	Highest score/area (top 3)
Above-elbow amputation	4	Extremity	✔

ISS = 4² = 16
This patient would meet the criteria for the use of the E420 code.

Example 4: Three-year-old child who fell from height:

Injury	Score	Body area	Highest score/area (top 3)
Thoracic vertebral fracture, >20% anterior compression, no neurological deficit	3	Chest	✔
Rib fractures, 2 ribs	2	Chest
Tibia fracture, closed	2	Extremity	✔

ISS = 3² + 2² = 13
This patient would meet the criteria for the use of the E420 code (>12 in patients <16 years of age).

Second Surgeon when required for a trauma patient

As stated on page SP3 of the Schedule, when it is required that two surgeons (same specialty) perform components of the same procedure on a trauma patient where the criteria for E420 have been met, each surgeon is eligible for payment of the full surgical fee for that procedure. The second surgeon is also eligible for payment of the trauma premium where payment requirements are met.

If the nature or complexity of the procedure requires more than one operating surgeon each providing a separate service in his/her own specialized field (e.g., general surgeon performing laparotomy and neurosurgeon performing craniotomy), then each surgeon should claim the listed benefit for his/her services – including E420 if payment requirements have been met.

Keywords/Tags

Abbreviated Injury Scale; AIS; calculation of Injury Severity Score; E420; ISS; OHIP Claims, OHIP Payment second surgeon; trauma patients; Trauma premium

Contact Information

For additional information, please visit the Resources for Physicians and the How to Get Help with Billing Questions pages on the ministry website.

If you have any billing or claims submission inquiries, please contact the Inquiry Services, Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint MOH/OMA Education and Prevention Committee.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly established the Education and Prevention Committee (EPC). The EPC’s primary goal is to educate physicians about submitting OHIP claims for payment for the insured service provided.

EPC Billing Briefs are prepared jointly by the MOH and the OMA to provide general advice and guidance to physicians on billing matters. EPC Billing Briefs are provided for education and information purposes only. The information provided in this EPC Billing Brief is based on the October 2021 Schedule of Benefits - Physician Services (Schedule).

While the OMA and MOH make every effort to ensure that this EPC Billing Brief is accurate, the Health Insurance Act (HIA) and its Regulations prevail over anything stated in this EPC Billing Brief. Changes in applicable statutes, regulations, or case law may affect the accuracy or currency of the information provided in this EPC Billing Brief. In the event of a discrepancy between this EPC Billing Brief and the HIA or its Regulations and/or Schedule under the regulations, the text of the HIA, Regulations and/or Schedule prevail.

Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.