By Bill Hennessey, M.D.
Ballad Health Bills Critical Care Codes Instead of ER Codes for ER Visit – Charges $4,664 for 10 minutes of Face Time with Patient
1. It took the patient 6 months to secure an itemized bill, known as a UB-04 bill (Uniform Billing.
2. This was an ER visit with a discharge to home as stable and no need for follow up care for an allergic reaction to a pill.
3. There was no ER CPT billing code (eg, 99281 – 99285). And so I said to myself “What the heck is going on? An ER visit without an ER billing code? But instead an obscure $4,664 ER cost.”
4. Is it ever any good when you hide money from your spouse of business partner?! This bill was hidden from the patient for a half year; however, under HIPAA law, her medical bills are considered a part of her medical records, meaning they are hers. The hospital had to cough it up.
4. CPT code 99281-25 was used. This is a critical care code with 30 minutes to 74 minutes of care. Yowza! Note: 10 minutes does not equal 74 minutes. Can you say upcharge? That’s the term used for jacking up a bill.
5. 25 modifier. This is a two digit modifier that is supposed to be used when a separate and distinct second medical condition with a separate type of care is needed. Example: bad car accident with a spleen laceration (needs a general surgeon) and a broken femur thigh bone (needs an orthopod).
6. In this case, she took a pill and had an allergic reaction. That’s it. One diagnosis – allergic reaction. Ballad didn’t think we’d see it and if we saw it, Ballad didn’t think we’d understand it. Ruh-ooh George! We do understand what is happening. This is also used to upcharge the care, also known as jacking up the bill.
7. Anaphylactic shock was the ICD-10 diagnosis code billed (bottom left code in photo T782XXA). This was not anaphylactic shock or anywhere near it. I know. How? I have common sense and I am a doctor. So why was this used instead of an allergic reaction diagnosis? IMO to help United let this slide with a critical care CPT billing code, Ballad needed to use a diagnosis code that justifies a $4,664 critical care CPT billing code.
8. The $7M doctor. That’s how much Ballad Health is billing Critical Care code visits in an ER instead of ER visit codes in an ER. $4,664 for 10 minutes with the patient – not 74 minutes. Even at every 74 minutes, that’s stating an 8 hour ER physician workday being billed at $30,254. At 5 days a week with 3 weeks of vacation and holidays off, or 236 workdays per year, that’s a staggering $7,139,944 billing for one ER physician per year for the hospital facility fee with Critical Care CPT codes instead of ER codes. I know what Ballad is doing.
9. $49 for one liter of salt water. Her care is worth $706 but if Ballad wants $5,000, one solution recommended is the delivery of two cases of two liters of salt water to Ballad’s medical supplies department since they value salt water so much.
Don’t be bullied. Be the bull
Been watching this kind of crap for years. Yet, it continues. FSER’s are just as bad, and they continue to get away with it. – San Antonio physician
