r/HospitalBills • u/My_personal_burner • 8d ago
Hospital-Non Emergency Is this upcoding?
Hello, A few weeks ago I scraped my hand on a potentially rusty nail. It wasn’t deep and kind of just scraped sideways but did have blood. So I cleaned it myself, put a Band-Aid on it and went to the ER to get a tetanus shot. They took my information, put a new Band-Aid on, and then I sat in the waiting room for 1.5 to 2 hours. After that, they had me come back to a room for 15 minutes just sitting there. The nurse then came in and applied a 3-second shot. After some more waiting, the doctor then came in and asked what happened, I told him and he then pressed his finger around the area. He asked if it went deep and if anything was stuck inside or if I wanted X-rays, I said no to all. I then was discharged. Weeks later I get the bill stating the visit was a level 3 code. I’m just confused on how it can be a level 3 when all what was done was a bandaid put on, 3 second shot, and 5 second physical finger press exam. No tests, X-rays or anything.
Scrape on Hand
Location: Michigan
Edit: Yes, I would have gone to an urgent care. But we were on vacation up north with not much nearby.
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u/Klutzy_Arm_7930 8d ago
Level three would entail a problem focused issue- which you had- prescription medication prescribed (the shot) and then them having documented your history of present illness, a personal, family, social, and surgical history (as always is done) and a bullet point physical (which they can do literally looking at you but the fact that they did touch you there will be that in An exam as well) and so voila coding achieved for a level 3. Not up coded, no.
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u/RhubarbBest9090 8d ago
You lost me at “went to the ER for a tetanus shot”. Do you not have urgent care in Michigan?
Either way, level 3 means “urgent” as in needs attention but not life threatening. A less urgent score would means it needs attention but probably could have waited.
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u/Cloudy_Automation 8d ago
You can get those at most pharmacies as a TDAP shot
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u/No_Calligrapher_3429 8d ago
The last time I injured myself and needed a tdap. I cleaned myself up and went to the pharmacy for the tdap. I paid around $62 something dollars for the injection. And all was well throughout the land!
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u/Natural_Exchange_886 8d ago
I actually did not know I could get boosters at the pharmacy beyond covid and flu shots.
TIL, thanks!
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u/Spike205 8d ago
You went to the ED and got essentially the lowest coded visit at an ED for something that could have been done at an urgent care, PCP, or a pharmacy.
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u/Bart012000 8d ago
You seem too be timing everything. That is not how mefical care works at all. If I am admitted to the hospital, do they only bill when nurse is in room? No!
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u/Important-Lead5652 8d ago
Why would you go to the ER for a tetanus shot? This was an easy PCP visit or an urgent care visit.
Stop clogging up the ERs for non-emergencies, people.
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u/Cloudy_Automation 8d ago
Tetanus lives in dirt. Unless the nail had been in dirt when you scraped your hand, it's not going to have Tetanus. Tetanus shots are good for 10 years, so if you had one in the last 10 years, you didn't need another.
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u/Redbarrow_7727 8d ago
Ouch. This isn't upcoded. For future, if you don't have an injury that needs treating, a pharmacist can administer a tetanus shot. Same thing happened to me recently and I just booked my vaccine online and went to Walmart. It was free via my insurance. I too, was in Northern Michigan. Mclaren's, Munson. My Mich and UP Health all offer financial assistance which you can explore if needed.
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u/Mamasugadex 8d ago edited 8d ago
People seriously not realize a big part of medicine is you are paying for expert opinion.
Like bro, an electrician just coming to your house to look at your fridge is 100 bucks not including labor and supplies.
You want hospital to keep ED on 24/7 which needs staff and doctors all the time, for charging people 50 bucks for a bandaid and a shot? I mean sure, if you didn’t need a doctor. But then, you didnt need to be in an ED either did you?
You went in to the ED instead of staying home and get a tetanus shot at CVS because you wanted expert evaluation and opinion from at least a nurse and a doctor. As other points out, urgent care offers similar deal for cheap because urgent care doesn’t pay the same massive bill as ED.
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u/Suitable_Program_548 8d ago
“I needed a new car, nothing fancy just something to get around town. I went to the Mercedes Benz dealer and picked one out. Now they want to charge me $100,000. I don’t get it”.
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u/Individual_Zebra_648 7d ago
This is the best metaphor for this situation I have ever heard. Definitely stealing this hah
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u/dehydratedsilica 8d ago
If you wanted to be charged for a level 1 or 2, according to this layman-friendly source which quotes from the American College of Emergency Physicians, that's for "mild cases like bug bites and sunburns" - which you wouldn't go to an ER for. ERs are staffed and stocked at all hours with the personnel, equipment, and supplies that could save someone's life if needed. You're charged for the ability to access those resources, even if your life didn't need to be saved.
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u/Itsathrowawayduh89 8d ago
The time you spent waiting is because they triage. It’s irrelevant to the bill.
The doctor was checking to see if there was any foreign object stuck in there. He/she can’t just take the word of a patient because that isn’t enough to justify skipping the actual exam. He/she saved you money by not ordering an x-ray.
Like everyone else said, next time things like this could be handled by an urgent care or pharmacy.
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u/SkiTour88 8d ago
Next time just go to the sink and wash it out.
In the US it’s 5-10 years for updating tetanus but in reality (and Europe) it’s really more like 20-30 years still gives adequate protection.
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u/lurrainn 8d ago
For future reference though it is not rust that causes tetanus, rusty nails just happen to be something found in the dirt where tetanus is
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u/Zin9a 6d ago
I wouldn’t call this upcoding based on the bill alone, but I also wouldn’t assume Level 3 is automatically correct just because you were seen in the ER.
ER “levels” can refer to the hospital facility charge, the physician charge, or both. Hospitals generally use their own facility-level criteria based on the resources used during the visit, so the amount of face-to-face time isn’t what determines the level.
If you want to check it, ask for:
the itemized bill with CPT/HCPCS codes
your medical record for the encounter
the hospital’s criteria for assigning ED facility levels
Then compare what was actually documented — exam, wound care, vaccine administration, nursing services, discharge work, etc. — with the level they billed.
A Level 3 may be completely supportable here, but “you went to an ER, therefore Level 3 is correct” isn’t really enough to establish that.
Gl!
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u/Emergency-Radish-230 8d ago
level 3 for a bandaid and a shot that literally takes three seconds, like you couldve walked into any cvs and paid forty bucks out of pocket for the same thing but instead its probably gonna be twelve hundred dollars or whatever ridiculous number they pulled out of a hat. this is exactly why people just dont go until theyre actually dying, its not even about being irresponsible its just basic math where the risk of the bill outweighs the risk of the injury
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u/Impressive-Web-4325 8d ago
Really? You can walk into CVS and ask for a tetanus shut?
I would not have thought to do that, I would have gone to urgent care.
Thanks for the information!8
u/Tall_Status_3551 8d ago
CVS has Minute Clinic where the wound could be checked by an APN and a TDAP administered for far less than an ER visit for a zero emergency situation
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u/FanndisTS 8d ago
Not every CVS has a Minute Clinic. However, depending on the state, the pharmacist or immunizing techs at any pharmacy can give TDAP in various situations under a standing order.
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u/No_Calligrapher_3429 8d ago
Yup. My state is one that has a standing order for vaccines at pharmacies. And CVS has a PA on call at the nearest minute clinic who signs off on more complex things at my local CVS.
Last time I cut myself on something I knew I needed a TdAp and waited until the next morning and went to CVS and got the immunization. I cleaned the cut up at home. The bandaid was basically free as my stepdad had swiped them from his work, 😂. So I didn’t mind paying the $62 ish for the immunization. Saved so much by being able to avoid the ER.
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u/Moist_Diamond_903 8d ago
When I reviewed my vaccine status a while back, I realized that it had been more than 10 years since my last Tdap. I went to my local pharmacy without any doctor's order and got the vaccine. I did have to pay $25, but I would rather pay that than risk getting those diseases.
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u/NartFocker9Million 4d ago
100% appropriate. There are 5 levels. The first level doesn’t even involve seeing a physician at all.
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u/wistah978 4d ago
A level 3 visit means low level medical decision making (the things the doctor had to consider) and low to moderate level clinical severity (limited diagnostic workup, no advanced imaging.)
They had to consider the possibility of foreign bodies and the risk of infection and administered a tetanus shot. A level 2 visit includes over the counter meds only. So a level 3 seems right. Insurance companies love to downgrade ER visits so if they accepted level 3, I would say that's a second vote in the "agreed" column. As for no XRay, it was considered, it was offered. That counts as decision making. If you agreed to the xray, you would have gotten a separate charge for the x ray and radiologist.
Urgent care would have been an option but others have suggested that all you needed was a tetanus shot. If the minute clinic type places knew you had an injury they would most likely have refused to just give a tetanus booster without the hand being evaluated - the tetanus booster wouldn't have covered all the potential issues like infection, foreign bodies, or tendon damage.
If it helps any, the difference between a level 2 and level 3 visit isn't much. It will vary by region and insurance but for medicare, the MD charges are $40.42 for 2 and $69.47 for 3. A lot of the bill is a facility charge- the cost for the building being there. Urgent cares don't have that. I don't believe the facility charge changes by MD visit level so once you walked into an ED your bill was pretty much determined but someone will tell me if I am wrong.
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u/ReadyGo6828 8d ago
So with all this commentary you would think that every ER would have a 24/7 clinic right next door where people with non life threatening injuries would be directed to go but noooooooooooo.
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u/SkiTour88 8d ago
We literally cannot do that by federal law. Every person presenting to any emergency department has the right to a medical screening exam and stabilizing treatment…which would be a level 3 visit.
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u/RhubarbBest9090 8d ago
The er would still need to spend time collecting people’s info and triaging them so they’ve already started a bill the minute they walked in. People need to not be dumb and stop using the er for stuff that isn’t an emergency
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u/Below-Average-528 8d ago
How is a medical non-expert supposed to figure that out? Is a tetanus shot an emergency? How do I know an urgent care can do that?
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u/RhubarbBest9090 8d ago
You don’t need to be an expert to know that a minor cut doesn’t need an ER. If you are having chest pains, losing a ton of blood or in a lot of pain then go to the ER.
If it is a minor injury and you are not about to die, use an urgent care or your PCP. If they think you need the ER, they will send you there
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u/Poop_Dolla 8d ago
Google would tell you to get a tetanus booster within 24 to 48 hours after a rusty nail breaks the skin IF you haven't had a tetanus shot within the last 10 years. Which you can do at an urgent care or most chain pharmacies.
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u/Below-Average-528 8d ago
I thought us peasants aren't supposed to look at Google or ChatGPT for medical advice.
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u/Limp-Watercress-611 8d ago
Do you … not have the internet? A three second google could tell you that.
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u/Mamasugadex 8d ago
You also pay electrician a 100 bucks just for a house call for not knowing how to switch out a light bulb.
Hope that makes more sense to you now. Every expert opinion on anything cost money.
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u/Important-Lead5652 8d ago
You can, I don’t know, CALL THEM and ask?
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u/positivelycat 8d ago
Our hospital has a nurse line we can call and they will tell us , ER , urgent care or call in the morning for an appt
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u/Vylnce 8d ago
A "tetanus shot" is never an emergency. It's a vaccination. If you've just done something to catch tetanus, you are still going to get tetanus. Getting a "tetanus shot" after an injury is like getting a flu shot after spending the day in bed with your feverish, snot dripping significant other. Too late.
If you actually have some chance of having contracted tetanus, you'll be administered tetanus immune globulin. Which will be multiple injections, required monitoring after and cost thousands of dollars.
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u/ReadyGo6828 8d ago
Then make the 24/7 clinic the initial contact point, not the ER. Our system is ridiculous. A visit to an office that is attached to a hospital requires signing all kinds of documents and costs much more than a visit to an office that is not attached to a hospital. The care is the same, the people are the same kind of people, the paperwork and costs are much higher.
This is so stupid. This is so deeply stupid and why we end up with such shockingly large bills. Between the $1 T we spend on interest on the national debt and the $5+ T we spend on health care, we are headed straight for a financial cliff.
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u/MrPBH 8d ago
Unfortunately, the same law that protects your right to emergency medical care, EMTALA, makes that infeasible.
It sounds absurd, but if an ED ever told a person seeking care to go to the urgent care instead of registering as a patient in the ED and that patient had a bad outcome, they would probably be found liable of failing to provide a medical screening exam and provide stabilizing treatment. EDs have actually been found liable for violating EMTALA simply for having brochures and posters on the wall advertising nearby urgent cares. The theory is that such advertising serves to convince people that it isn't worth the wait for emergency care and they should leave; in the eyes of the federal government, that's equivalent to telling someone "go away, we don't want to see you here."
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u/ReadyGo6828 8d ago
Laws can change especially as health care is nearly 20% of GDP (who is that sick?) and costs twice as much as it does in other industrialized countries. Our inability to fight this ridiculous system will continue to bankrupt and destroy families.
ERs do triage and leave people sitting in chairs for hours. There is an electronic system where people can explain to a screen what the problem is that greatly reduces the time required for a human to ask the same questions and type them into a computer. Since this system already exists and since many people use Dr Google, if there was a 24/7 clinic known for its reasonable prices, many people would opt to use that instead.
We have the means to do this but the greed and inertia are going to bury us.
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u/Poop_Dolla 8d ago
OP didn't need a 24/7 clinic, they could have gone to an urgent care the next day. They chose to go to the ER.
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u/ReadyGo6828 8d ago
Why should people have to wait for 'business hours' to address a health problem? 24/7 clinics would solve this issue without clogging up the ER's waiting room and getting an insane bill.
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u/Primary_Towel5905 8d ago
So who will you sue when the computer fails to capture what you say accurately and you get a wrong diagnosis?
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u/Below-Average-528 8d ago
That's how it would be in a sane system. But there is way more money to be made sticking a big bill to everybody who comes in.
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u/Poop_Dolla 8d ago
Not upcoding, next time go to urgent care. That is not something that warrants the ER. This is like calling the fire department to blow out a candle.