i should’a been a doctor

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.

EDIT: See the follow-up entry to this, where I talk about an excellent article that better describes Nursemaid’s elbow as an “annular ligament displacement”.

Comments

  1. 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.

  2. 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!!!!!!

  3. 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.

  4. 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.

  5. myrrh: OUCH! Wow, $1,500+ is sheer robbery. Good luck disputing this – it’s criminal how healthcare providers can get away with this.

  6. 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.

  7. 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..

  8. 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!!

    • R. Stein says:

      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.

  9. 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????

    • Scott Perrenod NP-C says:

      Yeah but I bet you would go out to a self absorbed dinner in (insert liberal city) and pay near that and consider a great night or pay near that to get your little cat treated by the vet and get it’s teeth cleaned and not bat an eyelash. You are all hypocrites. You will all deserve the crappy rationed healthcare you all want

  10. 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.

    • Harry Kanna says:

      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.

  11. micky dennis says:

    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.

  12. 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!

  13. 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..

  14. Harry Kanna says:

    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.

  15. 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.

  16. 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.

  17. 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…)

  18. 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.

    • Gee JM …. wouldn’t be a chiropracter eh? OBTW if a chiropractor is doing this …. it is illegal and not their prescribed scope. They CAN NOT set/relocate acute fractures or dislocations

  19. The only thing I can say to you guys if you think that you are smart enough, then go to medical school. Then see how you feel about billing and payment!! And do not apply a bad experience with one provider to all others!! How many millions of dollars are star athletes paid each year? Have they every came to the hospital in the middle of the night to care for and comfort one of you or your loved ones? I think not. I will NOT feel guilty about my fees. I have worked very hard and sacrificed a lot to get to this point. I’m not complaining, but it is the reality.

  20. Thank you Catkin above ….. As a family practice medical provider who has done many of these reductions: 1) To all the misinformed above “closed treatment” IS NOT surgery; “open treatment codes ARE!. As far as the $224 that is up to the office and the medicare % rate they are billing under. Also would you rather spend 8-10 hours in an emergency room with you child in pain and screaming AND be billed 5 times that? … then go ahead and tell your child later that $224 was more important than him or her. And BTW just to let you know that NATIONAL average the charge for a veterinarian visit is 130% higher than a human family practice/pediatrician visit and lets not talk about what this society values in salaries of athletes and movie stars ….

    • Scott Perrenod NP-C says:

      Thanks Scott …. Amen, as another primary care provider I try to educate these type of patients who complain about the full dimensional value of a very low density occurrence and the cost I show them all the 99213 reimbursements of about $49 to take care of all the multitude of long term chronic disease patients and sore throats, etc, etc!!!

  21. Sorry Scott & Catkin, it’s time for sane economics and choice in health care. Non-factual arguments about sport stars and veterinarians aside, Americans pay far more per capita for health care than other first world countries and get less benefit (see below). The Urgent Care charging $1000 as in our case to have our daughter touch a balloon to resolve her elbow is outrageous. No drugs, X-rays, even special manipulation. Just touch the balloon. $200 for the clever approach sure, $300 OK, $1000 is unjustified, unsustainable. Last year in Japan our daughter was treated in ER for a pencil stab in the cheek at $70 under her Grandmother’s ~$150 / month national health insurance plan. Japanese spend 1/3 per capita what we do for for first world care. With the Urgent Care I questioned the bill honestly thinking they had miscoded the “procedure”. Response, “Oh we should have warned it was $1K.” Time to at least impose the same disclosures simple mechanics are required to provide and consider the RN staffed tier 1 clinics as have been proposed. See:
    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/26/21-graphs-that-show-americas-health-care-prices-are-ludicrous/
    http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf
    http://www.theatlantic.com/health/archive/2013/02/how-much-does-it-cost-to-go-to-the-er/273599/

    • Scott Perrenod NP-C says:

      Hey Val … I am a NP but I am a doctorate prepared and board certified medical provider so your suggestion you pay less because you come to me is outrageous and class warfare targeted. Bottom line is service outcomes is service outcomes. Go to Canada and tell me how long the average time it is to get an MRI … I can order you one today and get you in a scanner tomorrow but you probably don’t value that until you need it!

  22. I understand doctors have to study and prepare for years to make procedures look “easy” but in this case, I’m sorry to say, this procedure IS easy. My pediatrician offered to teach me how to do it next time my daughter gets a nursemaid elbow, so I don’t think you need years of study and experience for such a procedure. Unfortunately, I learned this the hard way after going to ER and getting a bill that totaled $1275 ($600 plus doctor bill + $600 plus hospital bill, AFTER some insurance deductions). That is outrageous. And mind you, I have “insurance” but with deductible and also she didn’t even get Xrays done, we were probably there less than half hour and the doctor saw her and did the procedure in 3 seconds, nothing else was done to her (and by the way, we already knew what she had bec. of research on the internet). I mean, this isn’t right to charge so much for a procedure that can apparently be done by parents with little instruction.

  23. Scott Perrenod NP-C says:

    Unfortunately you didn’t and would you pay for financial advise from a financial planner or legal advise from an attorney on how to fill out financial/legal documents? But off course you complain if is medical providers, who because of the latter have to have huge malpractice insurance riders because of grumpy malcontents like ….. hmmmm , is the reason why your bill is so damn high and in the end the medical provider got probably about $175 for his/her professional evaluation and treatment of your child which apparently you have a price tag on how valuable it is ….. oh BTW most nursemaid elbows are caused by abuse and negligent parental actions …. luck you didn’t get CPS called on you!

    • That fact that you brought CPS into this conversation is enough to discredit you. This happened to my son and it was my fault. He was learning to walk and started to fall and I grabbed him to keep his head safe from the corner of the wall. I cried for days that I was the one to injure him. He went in and saw the NP just an hour later. And she told me how common this was and in fact had happened to her own child, and niece. She said this isn’t something to blame yourself for. Kids are fragile and you can’t always keep them from getting hurt. I was charged almost 400$ for something I was told over the phone wasn’t anymore different from a regular doctor visit if he was sick. So yes when I got the bill I was shocked. But I was more greatful someone was able to help him! But the fact that you threaten with CPS means to me you aren’t understanding and most likely do not listen to your patients and I pray for everyone that comes to you. CPS is a very serious claim. And not one you should throw around so lightly. Especially when there are so many poor children out there that truly need help from CPS.

  24. I think you’re response is out of line suggesting parents that take their child for a nursemaid elbow should get CPS called on them? Are you for real?! It is a super common condition for toddlers and could occur from innocently swinging your child or even another child can pull the child’s arm and cause this and thus the reason parents don’t get CPS called on them.. but just by this comment alone I can tell you have little common sense.
    And I’m not complaining about the doctor’s bill specifically but the current health care system we have that creates this situation of over charging for simple procedures.
    And yet you posted another comment (that i guess you deleted later): “Yeah but I bet you would go out to a self absorbed dinner in (insert liberal
    city) and pay near that and consider a great night or pay near that to get your little cat treated by the vet and get it’s teeth cleaned and not bat an eyelash.”
    First of all no I wouldn’t and IF I did, it would be my choice to determine whether the service or ‘procedure’ warrants the cost. In this case, all cost are pretty hidden until you get a bill weeks later and I do not have a choice in the matter.
    And no I do not have a price tag on my child’s well being but that doesn’t mean I have to agree with any exorbitant amount of money health care providers/health care system, whatever you want to call it, charge for a given procedure.

  25. Scott Perrenod NP-C says:

    Got it …. another example of choice determinant relativism. The whole (insert other country) is doing it better for (insert fraction) argument is specious when considered other factual certainty that all those other country’s citizens fly here for specialty care. If you want cost effective care:
    1. don’t go to an ER unless you are really sick or bare the cost of paying for the overhead for the privilege of being treated there.
    2. invest in an MSA
    3. Use and MSA to get into a direct primary care membership and finally
    4. stop always thinking everything is free or understand that you can go to second and third world countries and always get “cheaper care”
    5. Continue to monitor your EOB’s and definitely dispute questionable charges

  26. If the reduction is so simple and easy then do it yourself. Don’t go to the ER or your physician. But if you screw it up then it’s on you.

    Secondly, reimbursements are not set by hospitals or physicians. They are set by the centers for Medicare/Medicaid services. Insurances then set their payments based on those figures. All physicians or providers do is document the service they provide.

Speak Your Mind

*