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.

In celebration of the 2004 US Elections, I figured I’d link to a very apropos web comic called “Nuklear Power” that should remind us why this whole voting process is a ridiculous farse.

Update: The original link is now dead. Here’s an updated link to “Episode 403: Ad Campaign”.