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:
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.
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Joe Steele says:
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!!