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Isn't level 5 billing just noting that the diagnostic decision making was complex and complete enough to warrant billing that much? It requires that one perform
by epmaybe 9y ago
Isn't level 5 billing just noting that the diagnostic decision making was complex and complete enough to warrant billing that much? It requires that one perform a complete history, a complete physical exam, and warrant "high complexity medical decision making".
To use another example: You have a lump on your breast. It's either cancer or a benign cyst. Would you bill these differently for the diagnosis work on the doctor's part? Maybe I'm misunderstanding what happened in your situation, but if the same exact steps are taken in diagnosing appencitis vs gas, wouldn't you bill the same?
Edit: Oh I forgot to mention the main reason I commented. I have also heard that billing less (like level 4) even if you completed all the steps for level 5 but do not want to get flagged by the system for overbilling can in turn actually get you flagged for underbilling, and can be cause for an investigation/audit.
- deleted 9y ago[deleted]
- supercanuck 9y agoThere is no way of knowing. No standards exist between 1-5. You walk into the ER and hope it doesnt result in bankruptcy.
- epmaybe 9y agoI believe that standards do indeed exist, and they are called HCPCS codes. I had written a whole comment to your previous comment that got deleted, but please read the below wiki article to start. Note that the levels described in this article are not the same as your "levels 1-5". Those are CPT codes. For example, a level 5 billing for an emergency room visit is CPT code 99285. https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Coding_System https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co... Edit: also note that CPT codes are part of the HCPCS
- epmaybe 9y agoI'm going to reply to my own comment here as I think something needs to be said regarding my own opinion on this. I think that it's very obscure to patients as to what they might end up having to pay when they enter an ER. These codes are super complicated to me, and I think it takes quite a long time for medical coders to get proficient at their job. It'd be nice if patients didn't have to worry about these sorts of issues when receiving emergent care, but such is the country we live in.
- supercanuck 9y agoThere isn't a standard between what is a 1 and what is 5. There is a standard that they in fact exist in the first place and charged accordingly. But what one hospital considers a Level 5 and another considers a level 5, is based on the amount of competition the ER has, because there isn't another externality keeping it in check. The article touched on this, and I also discovered this through my own research when I attempted to dispute what in fact a Level 5 was. Add to the fact, that by entering into the hospital you are asked to enter into an arbitration agreement. Compound this with the monopoly nature of an ER, and the only thing keep prices from spiraling out of control is the sheer benevolence of the hospital employees.
- epmaybe 9y agoI think I understand what you are saying now, thank you. The only thing I have to offer is that regulatory bodies such as CMS and DHHS may have the authority to investigate these variations in level breakdowns, besides the sheer benevolence of hospital employees. Additionally, insurance companies would be understandably upset if a hospital was charging them more than they should have been, so potential investigations that shed more light on this could help stabilize this part of the market. I appreciate your insight!
- goialoq 9y ago> sheer benevolence of the hospital employees. and willingness to push back against intense economic pressure from management.