ER Visit? Did You Check Your Bill?

It all started a few years ago.  My son, Keegan, was 2 at the time he has his first febrile seizure.  While I am very familiar with seizures in adults, this was a very scary first experience with the knowledge I had at the time.  We rushed him to the ER, but by the time he was taken back into the triage area, he was already coming back to us.  Enough so that he fought the nurse trying to give him liquid Tylenol (which I later discovered makes no difference when it comes to febrile seizures).  I was just thinking that, at 2, he was already aware of the fact that the barrage of chemicals into his system would in no way help his immune system fight off his infection…

I recall vividly what occurred during this emergency room visit.  The most invasive thing done was a blood draw.  Just one (if you’ve ever been there when a toddler’s blood is drawn you know EXACTLY how many times the skin is pierced).  No imaging.  No spinal taps.  Basically it was a visit of reassurance to worried parents.

Later, after I fully educated myself on febrile seizures, I realized that this did not warrant a trip to the ER.  Basically, from an emergency room physician standpoint, the goal is to reassure the parents that there is nothing severe going on.

Another thing I remember vividly is a woman on a mobile cart with a computer asking me, on at least 2 separate instances that night, if I had insurance.  When I told her we would be cash (I carry a high-deductible plan) she really pushed the idea of me applying for AHCCCS (Arizona’s Medicaid program).  I refused both times and actually got a little perturbed with the situation.  Overall, I was anticipating a bill of $600-700, maybe $1,000, which I would manage to get paid.

I was NOT expecting a $3,000 bill.

Of course I requested the itemized bill.  I love how they send you a huge bill with a payment stub like I should roll over and accept that this is the bill.

The errors were many.  Billed for two blood draws.  Billed for a blood culture, which requires a very specific type of blood draw for accuracy that was not followed.  This was just a standard venipuncture that the hospital tried to bill a blood culture under.  And of course the $500 in labs that I could’ve had done for $70.

But the biggest shocker was the coding level used to bill the ER physician’s services and the ER code.  Level 5  -the highest.  I remember a patient who was in a roll over accident and was air-lifted to the hospital and billed a level 4.

There are a specific details that go into the billing codes (referred to as E/M codes).  One particular aspect to bill a level 5 is a high risk of morbidity or mortality.  That means a very serious chance that the condition that the patient is presenting with could create a bad outcome or death.  (There is a time component, but that was not an issue here)

So, basically, a required component to bill a level 5 for my son would’ve been a high risk of morbidity or mortality.  But recall that an uncomplicated febrile seizure is more of a reassurance type situation.

Me being me, I didn’t let the situation stand.  But the situation proved remarkably frustrating because the coders (the people who look at the medical records and make a determination of what should be billed) seemed to think everything was in order because the records had the “i”s dotted and “t”s crossed.  To them, this meant:

1. A comprehensive history. But this would require an extended history of the illness, complete review of systems and complete review of social history. Quite frankly, 4 elements to meet extended history were documented, but given the situation, it was done for reimbursement reasons and not because it helped Keegan.  (Really–a complete social history was documented! He was a TWO YEAR OLD!! How detailed can we consider any social / family history in this clinical scenario??)
2. The ER doc did a comprehensive physical examination. Interestingly, 9 systems were documented, the exact cutoff to qualify for comprehensive.
3. A high level of medical decision making.  But this case was really pretty cut and dry. To meet this criteria, the amount of data to be reviewed to meet “High” complexity would have to be extensive. Vital signs and limited bloodwork hardly meets extensive requirements.

Overall, this visit should’ve been billed a level 2 or maybe 3.  We’re talking about a $1500 difference.

So why do I bring this up now?  Because it appears that my situation is not an isolated one.  In this particular article, the author finds that the billing for level 5 ER visits billed to Medicare went from 27% in 2001 to 48% in 2010, without any apparent change in what patients are presenting to the emergency department for.

The author states, “The electronic medical record facilitates billing by presenting clickable check-boxes that easily satisfy coding-complexity criteria, and some EHRs even issue notifications when documentation needed for certain billing levels has not been achieved. These changes ensure that no billable action goes unnoticed and have reduced under-coding. In fact, EHR vendors tout this effect to justify the cost of their products.”

Wow, does this sound like my son’s ER visit.

The problem is that, especially in patients who have insurance, the hospital ER bill is never scrutinized, leaving many of these abuses to go unchecked.

If you have had an ER visit with a high bill, did you ensure that everything was billed correctly?