So, back in July of this year, my youngest daughter Suzanne dislocated her elbow, which is so common that it is referred to as “nursemaid’s elbow” (subluxation of the radial head), when we were at a picnic from swinging her by her arms. I thought I might have been able to successfully manipulate it back in when she was having her bath that night, but since she was still seemingly in pain the next morning, we took her to the Emergency Room at Chilton Memorial Hospital.
I learned several lessons from this whole episode:
Anyone can learn to properly manipulate a child’s dislocated elbow and should, if you want to save yourself money instead of going to a doctor.
From the dynomed.com link above, they say:
Most often, the doctor can just move the elbow back into place. To do this, he or she will gently bend the elbow to a 90 degree angle. The doctor will put his or her thumb over the elbow and apply a bit of pressure while starting to straighten the forearm. You might hear a snap when this happens, but that is to be expected.
Obviously, if you misdiagnose the problem (your child’s injury isn’t nursemaid’s elbow, and instead something more serious) you could do more harm than good. If you misapply the treatment, there’s also a chance you can do more harm than good, too. The correct manipulation for nursemaid’s elbow ought to be something taught in an infant CPR class (which, embarrassingly, I never attended) if it isn’t already.
The medical billing profession is totally out of control.
On the American Academy of Pediatrics website they have a page titled Top Ten Underutilized CPT Codes in Pediatrics, where #8 is:
8) Nursemaid’s elbow is a common occurrence in the pediatric population. Do you know that you can code for the treatment of it? 24640 (closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) is a “starred” procedure, which means that the code only covers the surgical procedure, not the evaluation and management that may be included. This means that you can list 24640 in addition to the evaluation and management code. Additionally, you should attach the -57 modifier (decision for surgery) to 24640 and note that it has a 10-day global period. This means that if a patient returns for follow-up within 10 days of the initial visit, you should not charge them for the portion of the visit that deals with the elbow re-check.
The doctor who saw Suzanne did bill us for procedure 24640, to the tune of $224. I mean, that’s $224 to bend your kid’s arm at the elbow and apply pressure. I’m aghast that the medical industry can even allow this to be called “outpatient surgery”, but apparently it can, and does!
I found references that indicate the CPT code 24640 reads:
24640* Closed treatment of radial head subluxation in child, “nursemaid elbow”, with manipulation
Out of curiousity, I wondered what exactly “closed treatment” means, and how this can even be considered “surgery.” I found the American College of Emergency Physicians website which has an Orthopedic FAQs page, which lists:
FAQ9. What is the difference between “open” and “closed” treatment of a fracture based on CPT definitions?
A. Per CPT definition, fracture care should be described by the type of treatment rendered and not by the type of fracture. Open treatment refers to the requirement for a surgical incision to expose the fracture for direct visualization. Closed treatment specifically means that the fracture site is not surgically opened. Thus, an emergency physician usually provides closed treatment only, even when caring for an open fracture.
So, it just means that the doctor didn’t require cutting the patient open (a surgical incision) in order to treat the fracture or dislocation.
After all this, it appears I’m “legitimately” (if you can call $224 a reasonable fee to apply pressure to an arm bent at the elbow) out $50 for the Emergency Room co-pay, and an additional $112.40 to the doctor since my medical insurance has a $100 deductible for “outpatient surgery” (which I still can’t believe this qualifies) and only covers 90% which explains the extra $12.40.
Now, I can clearly see why healthcare in this country is going down the crapper — the Hippocratic oath has apparently been been replaced with:
I swear to bill and collect from, to the best of my ability and judgement, this patient.
Soon, after the medical insurance companies disappear, it’ll be:
In God we trust. All others pay cash.
God bless America.
Programmer, husband, father, singer, guitarist, tinkerer, reverse engineer, strange, and living in New Jersey. 
I totally agree withyou. My son also had nurse maid elbow. I was shocked how they could call the procedure a surgery. My husband took our son since I was at work. I am a physical therapist. The doctor did not ice it at the office ans so it occurred again several hours later. I fixed it myself when I got home in less than 30 seconds and iced it. It did not occur again after that. I don not undersatnd how the medical community can charge $180 for something any lay person can perform. Just look it up on the internet.
Just had the same thing, but I got double dipped. Our doctor sent us to a specialist downtown at UAB (Birmingham, AL) so we were billed for two Doctor’s visits and a surgery. You’d think insurance would fight for us on this one. Oh yea, nevermind. They’ll just raise our co-pays next year to cover it!
It just so happens that the specialist we saw has the same last name as a doctor in our pedatrician’s practice. It smells like we’ve been had, and there’s nothing we can do about it.
For the money we’ve paid, I should’ve at least gotten a short lesson on how to diagnose and fix this next time.
Rock on Democrats…Universal healthcare for everyone. The Insurance/healthcare Industry is obviously honest and true so we need to make sure everyone in our country can be a part of it!!!!!!
Hi. I just evaluated my EOB and found that it billed as surgery to correct nursemaid’s elbow for my daughter. I looked to see if there are other codes available to show the correction of the dislocation. There doesn’t appear to be a better choice for the provider. I can assure you that if there was another code, the fees that we are charged would still be quite steep. I appreciate your research because your entry gave me the definition of closed versus open. Thanks.
At least your doc billed you for 24640, and didn’t bill you 24600 – closed elbow relocation without anesthesia =$866 plus 99283 -which is management and treatment =$203 for a 2 year old with nursemaid’s elbow at a total of $1,069 PLUS my ER bill and radiology bill for X-rays……I had to pay over $1,500 for a nursemaids elbow……. I know the bill is wrong, I am disputing because we pay out of pocket, and last time my toddler did this, it was a total of just under $500 total, with ER bills, doc bills and radiology.
myrrh: OUCH! Wow, $1,500+ is sheer robbery. Good luck disputing this – it’s criminal how healthcare providers can get away with this.
My 18 month old had this two weeks ago and we only stayed in the doctor’s office for about five minutes. The bill was $521 for “OP MISC. SERVICES”. I called the insurance and they were very impatient (the insurance did not have to pay anything because of my deductible) about my inquiry of what code used.
Hear my daughter’s saga…
My 2 year old daughter had elbow dislocation on a saturday afternoon and had to be taken to a urgent care facility. The urgent care was packed and it took close to 1 hr to see the doctor. This doctor(not a pediatrician) was clueless on how to fix the issue. She tried 2 times before asking us to get an x-ray and 2 times after seeing nothing wrong with x-ray. After 4 unsuccessful tries, she sent us home with a splint on my daughters arm and asking us to take her to regular pediatrician on monday morning and asked us to give motrin every 4 hrs. By the time we had x-rays and second visit with same doctor done it was 5 hours of wait with no resolution to this issue….
We had two days and 2nights of agony to me, my wife and ofcourse my daugher who could not sleep entire night.
On monday morning we had to fight with the receptionist to see the regular pediatrician that same day. The pediatrian fixed the elbo in 5 minutes after seeing my daughter and in 15-20 minutes my daughter was able to lift her hand and take her lollipop from the doctor. We were so relived and at the same time so pissed at the doctor from urgent care for not knowing how to perform this simple procedure…
It ended good so we thought untill we saw the medical bill for two days of treatment.
They billeded close to $1700 for unsuccessful treatment on saturday and $1000 for the treatment on monday…
I was sucessfull in getting the $1700 waived after talking to the medical director of the institute who was kind enough to intervine and resolve the misdiagnosis issue.
I am still disputing the $1000 charge for the monday’s service after all we had to go through..
My 19 month old had similar problem while I was sitting in a sofa and tried to lift him by holding his two wrists to put him in my lap and during which he complained about pain and he was holding his arm and crying saying “boo boo”. We were little upset and waited for 20minutes and it was 7.45pm and then quickly wanted to take him to urgent care which is five minutes away to be safe side. He was seen by a doctor for about 1 minute. He twisted and folded his arm for couple times. Though my son was crying until doctor fixed his arm(he normally cries every time a nurse or doctor touches him).
After twist and rotate doctor said this could be nursemaids thing and he asked us to take a x-ray and then walked out to make arrangements for x-ray and as it takes few minutes for operator to get it ready dr came back and was checking my son and my son started doing all high fives!! and my self and dr agreed to cancel the x-ray as he started moving his hand. Very nice!!!
Well after 2 weeks we got the insurance bill asking us to pay $150 as deductible and categorized as “surgery”. I got really mad at the medical system and called urgent care and she told me that it is considered as “procedure”. So I said, what is the gurantee that it was an “nursemaid” elbow in first place. There is no x-ray proof that some thing dislocated. As it is most common in kids, why cant this be treated like “viral fever” or “common/severe cough cold” kind of thing and billed as a doctor office visit.
Anyways, I am thinking of not to pay the bill unless they change the billing category. Lets see how it goes! After all its bad economy!!! who cares!! urgent care!!!
Btw, my brother (Cardiologist) and sis-in-law (Gynic) are both doctors!!
The charge for the procedure IS high, but part of the payment is being able to diagnose the nursemaids elbow in the first place. As several respondents have described here, a lot of docs (usually adult docs), don’t know what to do and rack up all kinds of ridiculous charges. So the 24640 is comparatively reasonable. When the doc knows what it is and immediately fixes it, she/he makes it look easy. But a lot of experience went in to that.
It is a wacky system that pays the doc for this, and pays nothing for the 40 minutes spent helping you breastfeed, or potty train, or solve bedtime problems. Nobody complains that the doctor spent too much time doing that.
Same experience. Saw doctor for 5 min, INCLUDING Q and A. Got a bill for $387.00. they won’t budge. Problem is we asked what it would cost and they told us it would be a normal doctor visit because the procedure was incredibly common and not a big deal. The Official Journal of the American Association of Pediatrics reads that this procedure is so easy to do that most doctors will tel parents over the phone what to do with nearly identical results, and for no charge! Insurance company said they, if they were paying for it, would have paid out around 125.00, or a normal doctor visit.
So, because we are paying cash, we have to pay triple????
First, if you think the physician is walking away with all that money, you’re insane. Most will only get a portion.
Second, the fee is not for the 5 minutes it may take to manipulate the elbow. The fee is for the ability of the person to make the diagnosis, treat the problem appropriately, and assume the liablility of having treated said problem. You’re not paying for the 5 minutes, you’re paying for the 11+ years of education/training that person did to be qualified to take care of the problem.
If you think that’s bad; look at lawyers. The lawyer that helped close on my house made 2 grand for doing some paperwork which his secretary probably did in about 20 minutes.
So you are comparing a doctor to a scum lawyer. Throw that hypocrite oath down the toilet.
Anyways, In our case a Physician Assistant working in doc group did the procedure & the group billed $2600 from insurance company. Because of majical discounts it came down to $650.
As a doctor or a hospital you need to have some justification for charging arm & leg. You can’t say surgery, OP. Sevices & hide the truth of the procedure.
I paid a plumber 120.00 to stick his hand in my sink and pull out a toy. He did not have to complete 4 yrs of college, 4 yrs of medical school, and at least a three year residency. Your doctor is paying for staff, outrageous malpractice insurance (thank those lawyers, who also are not trained nearly as long), student loans that take forever to repay, rent, etc, expensive vaccines,and supplies and labs which often insurance does not reimburse for. Every year insurance companies and especially government run ones, require physicians to do more and more, buy supplies which are not reimbursed, while compensating the physician less and less. Many pediatricians are closing their practices.
we’re going through the hoops with the hospital and Dr right now. We got billed $1,300 and have to pay it all due to my husbands company only offering a high deductible plan so everything comes out of pocket till we meet $3,000. We got the hospital to lower their bill by $130 by offering to pay in full and now we’re trying to get the Dr to lower his portion at least a little. $613 to see her all of 3 minutes. You can’t convince me that’s a fair price no matter how long he went to school for!
I am do frustrated what’s even worse is to hear this is happening to everyone. My 2year old came home from her grandparents house screaming in tears, hubby said his dad was playing an her arm popped, we took her to the ER unfortunately without health insurance, since it is not offere at either of our jobs. I recieved 2 bills. One for 601 from the hospital after a 100$ discount for not having insurance (which the nurse said was basically a bill to use the hospital) the second is for 717 from the dr who we never saw. We only saw a nurse and were in and out in 10 minutes. So I am under the impression that the Popsicle he gave her was $200 and then the rest for treatment? So frustrating. I understand it’s our bad for not having insurance, but when it’s $300 a month and we would still pay because of the high deductible?
No one will really explain to me why the bill is this high but after reading the posts I am going to see how it is billed further..
Same here. Billed $2600 for seeing two minutes that too by a Physician Assitant. Because of discounts they are asking us to pay $650 by our high deductible insurance.
Not sure what to think about our healthcare system.
We were charged $2600 ($1700 for Hospital & $900 for doctor) for 1 minute of bending the elbow excercise in ER for our 15month old daughter. With discounts it comes to $650. It was a physician assitant that performed the procedure but we were billed for an ER doctor.
The hospital charged $270 for nursemaid elbow while the doc charged $900 for the same condition.
This is insanity.
I just had the horrible experience from an urgent care facility near my home. I went there for my 1-yr old son’s nursemaid’s elbow. After waiting for 3 hrs, the “doctor” came in. My son started crying seeing a stranger and the “doctor” ordered an x-ray without even examining the elbow. My son was generally fine. He was able to hold and grab nicely, he only showed discomfort when trying to bend the elbow too much towards his chest. I knew for sure it was not a fracture as he never fell or hit anything. I was surprised when he ordered the x-ray but couldn’t decide whether to refuse in the limited time given. Finally, x-ray showed the obvious (no problems) and the doctor didn’t even try to fix the nursemaid’s elbow. Just suggested to follow up with the family doctor. I wonder if he is competent to do the simple procedure for the nursemaid’s elbow. It turns out that he did his medical degrees in Habana, and just started out in the facility last month. Though I only paid $25 copay, I am sure they will bill $1500 upward for this. As for us, my son is worse off due to x-ray both long term as well as the terrible discomfort while resisting to take x-ray. The insurance company will still have to feed these incompetent doctors.
This happened to us! Ours was $619, and we got to pay $377. Highway robbery. Same code, plus “office visit.” Golly. The 30 seconds to pop it in, plus I guess the hour-plus waiting at the urgent care (which doesn’t have an ER, x-ray, etc. Just “quick” way to see a regular doctor…)
I had the same problem. Called the insurance and complained, since I knew what was wrong, just needed the dr to fix it. They changed the coding and I didn’t have to pay more than my copay. FYI of you take your child to a chiropractor they can go it for the cost of your normal visit/copay.