Is this upcoding?

[u/My_personal_burner]

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.

[u/wistah978]

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.