r/HospitalBills • u/Additional_Leek_2937 • May 14 '25
Urgent Care Crazy Clinic Bills
recently went to an urgent care for a localized infection.
No tests were performed, the entire exam took about 60 seconds and involved the "care provider" asking me how I'd treat my condition (and then doing that)
Since then I've gotten bills from the clinic and provider totalling almost $700. Is this now the norm? Is it customary for a clinic to demand even more than the provider for simply providing a venue?
Update: codes as 99204 for both bills, 370 to the clinic and 310 to the provider.
3
u/justhp May 14 '25
This likely qualifies as a 99204. The requirements are pretty easy to meet.
You can always ask for a coding review, but prepare for the code to stand.
2
u/Mcipark May 14 '25
$700 seems a bit steep for an urgent care, even pre-insurance adjustment. Go check out your EOB on your insurance provider portal and get some more info
2
u/Additional_Leek_2937 May 14 '25
Pre insurance was 800 a piece (exact same code). So total would have been 1600 bucks.
2
u/Mcipark May 15 '25
Just realized you said it was $700 for two visits, so basically $350 a visit. This is extremely close to a typical price for an urgent care. It sucks but you’ll likely have to pay it
2
u/MNrunner19 May 14 '25
It is a facility charge. Depending on how the UC is set up they can bill that way. Basically the same as ER billing or outpatient hospital billing. You can ask for a coding review to make sure the level of service is supported. I am not a coder but work in medical billing and am a go between for patients who are disputing their bills so I see all the coding reviews that I send for review and what the response was. If you had no meds or labs I would suspect 99213 is the code for both unless you were a new patient then 99203.
1
u/Additional_Leek_2937 May 14 '25
99204
They haven't responded with justification but I've read up that sinus infections are acute, uncomplicated when there's no systemic symptoms associed (like fever).
They also ordered no tests, just wrote whatever script I asked for and left (even asked me for what dosage I was expecting)
4
u/MNrunner19 May 14 '25
You got a script. That is going to put you at the 99204. Level 4 and new patient. You could ask for a coding review but I suspect it would come back correct.
1
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u/dadayaka May 14 '25
Did you say anything about being short of breath or having a cough?
Fever doesn't actually fall under systematic symptoms. Fever, body aches, and fatigue are typical symptoms of an infection and aren't necessarily signs things have moved out of the local level. However, cough and SOB can be signs it's moved from sinuses into the airways and lungs.
That coupled with a prescription would qualify at 99214.
Depending on the hospital/physician group and insurance this could actually be the very lowest they can charge. You can (and should) request a detailed bill to ensure what exactly was charged. If they have a portal the doctors notes are typically entered there after a few days. The notes will give you an idea why the coder may have picked systemic vs uncomplicated.
If there is nothing that can be contested on the doctor side, check your insurance EOB to see if they not any reason they paid less then normal. You aren't necessarily looking for a denial, though. Just a reason code.
And finally, call the doctor groups billing office. They will often have options like payment plans and even financial aid.
2
u/Highstakeshealthcare May 14 '25
To start with, for 60 seconds, using a 99204 is a severe case of upcoding. Did you use insurance? Was it a hospital owned urgent care facility?
1
u/Additional_Leek_2937 May 14 '25
Insurance, yes.
It's an afc clinic, no idea if it's affiliated to a hospital.
3
u/Highstakeshealthcare May 14 '25
It just shouldn't be this hard or expensive to get healthcare in this Country (or any country). Before you pay them, send this letter (just copy and paste and change any details if I don't have them correctly written). Don't call them - calls never get anywhere. This may not either but our healthcare system depends on patients not knowing how to dispute anything or to question them.
Re: Patient: [Patient Name]
Date of Service: [MM/DD/YYYY]
Account/Claim #: [#]
Billed CPT: 99204To Whom It May Concern:
I’m writing to request an immediate correction of the above-referenced claim. The encounter on [Date] lasted under two minutes and consisted solely of a brief prescription review—well below the time or complexity thresholds for a 99204. Accordingly, the service should be down-coded to the appropriate level (e.g., 99202).
Please :
- Reprocess this claim with the correct CPT code reflecting the actual service provided.
- Send me a revised itemized statement.
- If you choose not to correct the code, I request justification for this code prior to payment.
Thank you for your prompt attention.
Sincerely,
2
u/Highstakeshealthcare May 14 '25
There is NOTHING in that description that justifies a 99204. That code is for an office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
I've owned a TPA for 25 years. We always have these down-coded before payment. We don't deny payment because we don't want our members billed but we always ask for justification and they automatically down-code it because they don't have the justification.
1
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u/Old_Draft_5288 May 15 '25
For 2 visits, it’s entirely accurate and normal. It’s not just the codes that are adding cost - you had two separate appointments with providers, so usage is built into that cost not just the diagnostic code.
1
1
u/Environmental-Top-60 May 16 '25
Depends on locality. We charge about $475 in clinic to insurance but self pay is way cheaper.
What matters is what medical decision making went in that visit and whether it's integral to the procedure.
5
u/voodoobunny999 May 14 '25
Codes, please?