r/HospitalBills • u/Greedy-Journalist962 • Jun 25 '25
Urgent Care Is this upcoding practice
I suspect that an urgent care facility up-coded my visit. My son, 2 years old, was sick so, we took him to urgent care where a physician assistant saw him for no more than 10 minutes. I mentioned that he put fingers in his ear and she automatically checked his ears and diagnosed him with ear infections, he also noticeably had congestion. She asked me about fever I told her that low grade no more than 100.3 F at highest. She mentioned that she will send in prescription for antibiotics. THAT is it, no more than 10 minutes. Well I get a bill for office/outpatient new moderate Mdm 45 minutes. The bill is $527. I called the facility and spoke with the billing manager to review my coding charge and she agreed to do so however, she believes that it will remain in place and offered 100 dollars discount. I believe the coding charge should be 99203 which would bring it to $329. The manager argues the mention of fever would bring this up. However, 100.3 is not even considered a fever according to medical professionals. I truly believe this is being up-coded or am I wrong?
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u/ElleGee5152 Jun 25 '25
E&M coding criteria is time based OR based on medical decision making. If they based the code selection on MDM (which most do), the time likely wasn't documented since it's not a requirement.
OP you may want to take this to the medical billing & coding subreddit to get the opinion of professional coders since it's a coding question..
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u/Greedy-Journalist962 Jun 25 '25
Thank you very much for the response. I am fairly new to reddit. Can you guide me please where to find the billing and coding subreddit. Thank you.
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u/kirpants Jun 25 '25
Based on the information provided 99204 is likely appropriate. Source : I am a coder.
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u/Greedy-Journalist962 Jun 25 '25
Thank you very much for your input. Will keep posting what they will come back with.
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u/voodoobunny999 Jun 26 '25
I can see that you’ve been plastering this on every healthcare-related sub on Reddit. Taking account of that, along with what you’ve written about your intentions regarding regulatory authorities, as well as my not insubstantial experience in healthcare, I recommend that you pay your bill.
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u/Greedy-Journalist962 Jun 26 '25
Wow wow! Plastering on every subreddit? That is a strong assumption and strongly inappropriate of you. Your suggestion will not be taken into my consideration. I only posted on this subreddit as another person sent me the link to this one and said to ask the question here instead. So calm down with your rudeness. If you have nothing good to say keep it yourself. Thank you and goodbye!
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u/MagentaSuziCute Jun 25 '25
Visits can be charged based on time (both face-to-face and non-face-to-face) on the date of the encounter or medical decision making. Based on what you have provided, if it was billed using mdm, I would have coded 99203 (if there were no tests run at all).
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u/Greedy-Journalist962 Jun 25 '25
Agreed, no major tests. Looked in both ears, mouth, checked breathing. The nurse checked for vitals like fever, oxygen level. That is it.
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u/MagentaSuziCute Jun 25 '25
This is a " low" for number/complexity of problems addressed (2 or more self limiting/minor) and maybe an (acute uncomplicated illness). No data and moderate risk (prescription) that would map to a 99203. However, the amount of time spent charting and getting the script called in, could change the level. It should be documented in the note. If you have that, post a redacted copy and I'm happy to take look.
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u/Greedy-Journalist962 Jun 25 '25
Thank you so much for your willingness to help. I will look online to see if they gave more detailed information there. The bill itself doesn’t even have a code on it, just the charge and the physician assistant name.
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u/Botasoda102 Jun 25 '25
Good luck. Most medical practices will charge 99204 for a new patient, or 99214 for an established patient, when a prescription is written. You might get them to change it to 99203, but wouldn't count on it.
If you have insurance, they'll likely approve $200 or so for a 99204.
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u/Greedy-Journalist962 Jun 25 '25
I do have insurance but, it was out of network and they didn’t pay anything. Honestly that is all that I want them to do is change the coding to 99203 as 99204 is not justified. Both coding state that they are new patient but the time spent differ. I am not asking to make the bill 0. I just want fair coding that was justified in my case.
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u/Botasoda102 Jun 25 '25
I'd offer them around $250. They would have been lucky to get $200 if it had been an in-network provider covered by insurance.
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u/peanutleaks Jun 25 '25
That’s wild I was billed 200 and change for 7 stitches…..back in 2018 tho…..
However one day in 2023 I was billed 50$ just for getting vitals checked while they called an ambo and carted me off……LAME!
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u/Greedy-Journalist962 Jun 25 '25 edited Jun 27 '25
Unfortunately this is how the system works. In addition they get to say that you mentioned fever, which I didn’t by the way. She asked and I simply told her what it was. And apparently that can constitute complexity and there for ~$200 more. There is no justification for this behavior.
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u/tired-of-it8511 Jun 26 '25
It’s really shouldn’t as with an ear infection especially with kids there are fevers. So that shouldn’t change the code. But these days who knows anymore. My friend’s psychiatrist billed a med visit ( that what she sees him for) then he billed a psychotherapy visit because he asked her about exercising and he talked to her on that. I told her well he is right and he is wrong. 1) he sees her for her meds so bill that 2) he changed the subject so he was able to but I have never ever she a psychiatrist bill for anything other than a med visit even if they ask about things. I told her to tell him and you only talk about meds and I talk to the therapist about my other issues. She did and I guess he said are you telling you think I’m being a fraud. I know if you a doctor for a physical and you tell them you have a sore throat they can bill a physical and an office visit.
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u/Greedy-Journalist962 Jun 27 '25
This is exactly what I mean. They ask one question and that question can change everything on the billing. By the way I had experience similar situation before so, I know that this happens in medical industry in this country.
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u/dadayaka Jul 01 '25
Medical Coder here. Specifically specializing in urgent care/office visit coding. MDM (medical decision making) is based on 3 categories; complexity, data, and risk from treatment; OR on time. Most places use the 3 category system because time based requires detailed documentation of time spent on the case (this does not just include time spent with patient but also afterwards updating charts and making notes). When using the 3 category system, coding its based on the level set for 2 of the 3 categories.
For Complexity, this one is hard to say without seeing the doctors notes but, most likely, due to the low grade fever and congestion the doctor likely noted as systemic symptoms. Also, due to your sons age, the risk of not treating an infection of any kind is higher than for an adult. Ear infections in that age group are also often preceded by or followed by an upper respiratory infection. Depending on how the doctor noted it, I'd set this as Moderate for Complexity.
For data, it seems pretty limited but him being 2 means he needed an "independent historian" to tell the doctor what was going on; aka you. This places it as Low for Data.
Finally, any time a doctor prescribes something the Risk category is automatically Moderate or higher.
2 of the 3 categories would be considered moderate so it would be coded as a 99204, not a 203. I'm sorry if you disagree but based on guidelines set by CMS this was likely coded correctly.
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u/Greedy-Journalist962 Jul 03 '25
I really appreciate your comment and explanation. Thank you for taking the time.
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u/DoritosDewItRight Jun 25 '25
Ask the billing manager to provide all medical notes from your visit, and to explain what the physician assistant was doing for the other 35 minutes when they weren't seeing your kid.
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u/Greedy-Journalist962 Jun 25 '25
Thank you very much for your response. I will ask her to provide that in writing if the coding review stays.
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u/SupermarketSad7504 Jun 25 '25
I do not understand where you think this will go?
You were out of network, your insurance paid nothing.
Changing the code - ok so what ? You're out of network, she charges you the same price or $100 less.
She already offered a $100 discount.
I don't understand your end goal?
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u/Greedy-Journalist962 Jun 25 '25
My end goal is to pay $329 for code 999203 which states “new patient office visits involving low-complexity medical decision-making and a time-based selection of 30–44 minutes.”!
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u/LowParticular8153 Jun 26 '25
What do you mean insurance did not pay? Was it applied to a deductible? Contingent on diagnosis, time, date most insurance carriers approve something.
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u/Own-Emphasis4551 Jun 27 '25
OP noted the claim was OON.
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u/LowParticular8153 Jun 27 '25
But unless it was like a true rigid HMO like Kaiser OON would cover something.
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u/Greedy-Journalist962 Jun 27 '25 edited Jun 27 '25
Our insurance is from market place the cheapest there is and we were out of network so, it must have went towards maximum out of pocket cost.
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u/Greedy-Journalist962 Jun 25 '25
I completely understand that no definitive answer can be given. I described my case from my perspective as I am sure there are medical reasons for different coding and up-charges. However, I truly believe that I am being wronged here to the extent that I am willing to file complaints to HHS-OIG, the attorney general, BBB, CFPB even medical board so they investigate ethic of the physician assistant. Upcoding is completely unethical and illegal and if they are not willing to correct a mistake, if it was a mistake, then there are legal repercussions for their actions. Diagnosing a child with ear infections and prescribing antibiotics should never be a 500 dollar charge. It was a simple straightforward visit in which I told the physician straight forward his ears need to be looked at.
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u/voodoobunny999 Jun 26 '25
You don’t get a discount because you helped.
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u/Greedy-Journalist962 Jun 26 '25
Very helpful person here. Thank you for your feedback and keep your snarky comments to yourself.
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u/LivingGhost371 Jun 25 '25
Some points I want to make as a health insurance company claims processor