Decoding Upcoding in the Emergency Department

Health information management (HIM) professionals have long touted their expertise in the practice of coding—and decoding—health data. While their jobs require coding professionals to take a patient’s encounter with a provider and translate it into a claim, they are also skilled at cutting through the jargon and helping patients understand what exactly they are paying for.

This skill is becoming increasingly important in an era where the cost of healthcare is rising steadily—and despite industry assurances to the contrary, the cost of care is anything but transparent.

In a webinar on Wednesday presented by the Center for Health Journalism called “It’s the Prices, Stupid: How Sky High Prices are Crippling Our Healthcare System,” Sarah Kliff, the senior policy correspondent for Vox discussed a recent article about hidden “facility fees” included in emergency department (ED) billing. Kliff’s article, “Emergency rooms are Monopolies: Patients pay the price,” profiles a patient who visited his local ED for severe back pain. He was given a muscle relaxant and discharged quickly. His bill, however, was $2,429.84—seemingly disproportionately high in comparison with the care he received. In today’s webinar, Kliff mentioned another Vox reader who sent her his ED bill, which totaled $629. In this case, the individual took his daughter to an ED after his wife trimmed their daughter’s fingernail too close to the skin. The ED charged the parents $7 for one Band-Aid. A murky “facility fee” was the remaining charge and became the subject of a year-long Vox investigation into emergency department billing.

Kliff described how, through social media outreach, she was able to collect medical bills from over 600 people in 48 states to create a database of ED bills that patients wanted decoded for them. Vox and Kliff worked with HIPAA experts for over a month to create a secure database that could properly protect the volunteers’ protected health information (PHI). Then, they created a network of experts, including ED coders and billers, doctors, nurses, and payers to consult with to help explain the CPT codes and itemized charges on patient claims.

Kliff has been working with the Health Care Cost Institute (HCCI) and its president, Niall Brennan—formerly the chief data officer at CMS—to study ED cost trends.

According to Brennan’s data and Vox’s investigation, nebulous “facility fee” charges are the unpublished price of walking into any given ED, regardless of the services provided. Hospitals say it’s the price they must charge to keep their doors open, Kliff found.

“Overall spending on emergency room fees rose by more than $3 billion between 2009 and 2015, despite the fact the HCCI database shows a slight (2 percent) decline in the number of emergency room fees billed in the same time period,” Vox reported.

Emergency Coding Implicated

In response to soaring overall healthcare costs, HCCI’s data found that coding professionals and hospital billers are being pressured to essentially upcode ED claims. Hospitals are increasingly using level 4 and level 5 codes—the highest levels available—to bill for basic services. For example, Kliff cites one man who knew he had strep throat but couldn’t find an open urgent care center, so he visited a local ED. The doctor prescribed IV antibiotics and inexplicably ordered a CT scan. His claim was coded at the highest level—a 5—the same as a serious auto accident injury. The ED charged a $1,900 facility fee.

According to Brennan’s data, this scenario was not atypical.

Brennan and Kliff were not optimistic that healthcare costs would improve in 2018.

“2018 will be a year of consistent uncertainty. Moving away from putting all our chips on value-based care. Programs being cancelled or rolled back,” Brennan said during the Q&A portion of the webinar.

Kliff encourages consumers to call their providers about irregularities in their healthcare claims.

“About half of the bills in our database have charge data breakdowns. A lot are much more general. I’ve found hospitals when asked for itemized bills, that hospitals like to provide that information, but that’s not always the case. One of the things you have a right to do is ask the hospital for detailed information. That’s a place to start if it’s not on the bill already,” Kliff said.

Mary Butler is the associate editor at The Journal of AHIMA.


  1. This article is very misleading. Since there are not any government standards for ED facility billing, hospitals are on their own to figure out a metric for charging ED facility fees. Even though hospitals have to bill these fees using the CPT ED E/M codes, the professional coding guidelines do not apply. Hospitals base the code levels on the intensity of non-billable services, such as nursing care. Quoting that “the doctor prescribed IV antibiotics and inexplicably ordered a CT scan” has no merit on the facility fee charged. Frankly, I am surprised that AHIMA published such a one-sided article.

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  2. You mention the cost increase between 2009 to 2015 but what were the increase in ED Visits during that same time frame?

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  3. This article fails to acknowledge the fact that many ER visits are basically “complimentary” due to a large percentage of patients taking advantage of government (taxpayer) assistance.

    They visit ER’s because it is more “convenient” than waiting for an appointment at the clinic. They present to the ER and utilize staff and resources even though their complaint is not emergent or life threatening. This is because they have no concern that they will ever receive a bill for the services.

    Unfortunately, as is commonly the case, the people who do pay their bills and have insurance take on the brunt of these costs.

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  4. Since facilities continue to attempt to adhere to CMS directives without a directive – and base their level assignment on resources –
    I would think the CT scan (resource machinery and technician) although I am not sure how they supported medical necessity unless the pt was totally unable to swallow, and the IV set up and monitoring by facility staff – is at the base of their idea of supporting the high level for facility resources…….

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  5. Our entire healthcare system is completely out of control! I’m glad in Texas our insurance providers must pay for any “emergency care”. We now have a freestanding emergency room in Houston and they provide such great care and at a great price. I wish more medical care was like this!

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  6. Interesting information. I didn’t know about this. Seems like the other comments have something to say about the matter as well. The ER I use, Memorial Village ER, always works with me so that it is affordable.

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  7. I am only familiar with billing ER codes for physician services 99281-99285. Tell me about facility billing in the ER.

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    • Dee, Basically most ED visits have 2 bills, the physician side & the facility side. If you bill for the physician part only, the facility codes & bills for their part which may not be the same as the physicians’ levels, as Sherri states above a facility bills for any other resources used, nurses, technician’s from lab, radiology, respiratory, maybe even social services or mental health as well as physician documentation. They use the same CPT E/M levels 99281-99285

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  8. I was sent to our local hospital by the doctor at the walk in clinic, he indicated I should have a CT scan at the hospital and he would call ahead and tell them I was coming. I have went to the hospital for MRI’s so that didn’t seem so unusual….until I got the EOB where my insurance was billed $1177 for “Emergency Services”. I knew I would have a bill for the CT scan and have no issue with that. I should mention the walk in clinic and the hospital are owned by the same corporation, Confluence Health. I paid a $30 co-pay at the walk in and $150 co-pay at the ER. I was coherent, no blood was drawn, no iv was given and I saw the nurse 3 times, once when she told me to get undressed and she felt I might need the heart monitor- just “might” not necessary. She hooked me up and the machine periodically squeezed my arm and I didn’t see her again until she gave me a shot that cost $158 and the medicine was $5!! I did have the CT scan , saw the doc twice, nothing special about his visits – the walk in doc had done a neurological exam so he didn’t and I slept for 2 hours, given persciption for pills for vertigo and sent home. The nurse entered my visit as a Level 4 visit and so my insurance was charged the $2255 which included the $1177 for emergency services, the $158 for the lump in my arm where I got the shot and the CT scan. On top of that there was the radiologist bill $171 and the doctors bill for $306. I was still sick two days after I left and had to pay another $30 co-pay to see my regular doctor!! I went to the Hospital thinking I was getting a CT scan and left owing $3000 for nothing!!

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