Emergency room visits are notoriously expensive. Just a few hours in the ER can cost you thousands of dollars, even if you’re insured.
But how is your ER visit cost calculated, and how can you tell whether your hospital bill is correct?
We scored some insider tips from Goodbill medical coding expert Christine Fries, who has analyzed thousands of ER hospital bills for accuracy. Here are answers to frequently asked questions we get from Goodbill customers about how to understand and vet ER visit costs.
Patients are usually surprised when their first ER hospital bill is quickly followed by a separate hospital bill with similar-sounding charges but different amounts. This is normal and a byproduct of how hospitals bill patients for the services rendered at the hospital, Fries says.
The institutional bill, also known as the facility bill, charges you for the procedures, tests, and administrative costs from the hospital.
The professional bill, also known as the physician bill, charges you for the work and time of the physician who treated you. This generally includes services from doctors, anesthesiologists, or specialists who are affiliated with the hospital but aren’t employed by the hospital.
Expect to get two bills from your ER visit — one for facility charges, and the other for professional or physician charges.
For more information on the different types of hospital bills, see our itemized bill guide. Goodbill currently helps patients negotiate institutional bills, not professional bills, so our guidance below pertains to institutional bills only.
It’s important to remember that your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis, Fries says.
When a patient walks into the emergency room complaining of chest pains, for example, the hospital’s objective is to run tests and administer procedures that can help rule out life-threatening conditions. Even if the doctor ends up discharging the patient with a non life-threatening diagnosis like indigestion, the hospital has already spent the resources to rule out more severe possibilities like a heart attack.
Your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis.
“Look at your symptoms first, not what you were diagnosed with,” Fries says. “The level of your ER visit is guided by the symptoms you described, and by the tests the hospital thought were needed based on those symptoms.”
Hospitals will bill you for a line item called “ER Visit Level” that is based on the complexity of your treatment. ER visit levels range from 1-5: ER visit level 1 is the most mild, while ER visit level 5 is the most severe. The level also determines how much the hospital can charge you, from least expensive to most expensive. You may sometimes hear ER visit levels described by their corresponding Current Procedural Terminology (CPT) codes of 99281, 99282, 99283, 99284 and 99285.
To decide the proper ER visit level, hospitals typically follow certain guidelines from the American College of Emergency Physicians (ACEP). ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says.
“Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there,” Fries says.
The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common.
Here’s a simple rule of thumb for determining whether your ER visit level was correctly assigned.
An ER visit level 4 typically requires a minimum of two diagnostic tests — like a lab plus an EKG, or a lab plus an X-ray. Or, any administration of fluids through IV will automatically qualify your visit as an ER visit level 4.
An ER visit level 5 typically requires a minimum of three diagnostic tests — for example, a lab plus EKG and X-ray. Or, any type of imaging scan like a CT scan or MRI where a patient must ingest or be injected with contrast material, will automatically qualify your visit as an ER visit level 5.
Many female patients get frustrated when they’re charged for a pregnancy test, even when they’re absolutely certain they’re not pregnant. But this is standard practice and a way for hospitals to protect against unknown pregnancies, Fries says.
If you’re an adult pre-menopausal female, you can count on being asked to do a urine or blood pregnancy test before the hospital will treat you. It’s too risky to both the patient and hospital to administer injections, scans or drugs in the off chance that a patient is unknowingly pregnant.
If you're a female, expect to get a pregnancy test during your ER visit — even if you're not pregnant.
On your itemized ER bill, your pregnancy test will usually show up with a description like “human chorionic gonadotropin (hCG),” which is the hormone being tested. This charge will generally fall under the CPT codes 84702 or 84703 if it’s a blood test, or 81025 if it’s a urine test.
Here are a few common procedure names that often show up in your ER visit costs, and what they mean in plain English:
This is a bundle of lab tests run from a single blood draw. Patients may get a “basic” metabolic panel under CPT code 80048, or a “comprehensive” metabolic panel under CPT code 80053. These panels cover a set of individual tests that might otherwise be individually charged. For example, a “comprehensive” metabolic panel must include testing for all of the following:
Any time you get your blood drawn through a needle, this charge under CPT code 36415 is the line item that bills you for the needle.
This test under CPT code 83690 measures your levels of lipase, which is an enzyme that helps break down fat in your intestines. Your lipase levels may be elevated if you have pancreatitis, which is an inflammation of the pancreas gland.
When analyzing a patient’s ER visit costs for errors, Fries says she goes straight to one place first: Hydration services. If you recall being administered fluids through an IV bag, chances are you got hydration services during your ER visit.
“Hydration services should always be questioned,” Fries says.
Coding guidelines require that the two CPT codes for this service, 96360 and 96361, meet a minimum time requirement of 31 minutes in order for one unit to be billed. These 31 minutes must also be “stand alone” — meaning that the administration of the service cannot overlap with any other type of infusion service. Often, hospitals don’t meet these requirements, rendering the charge unbillable.
Hydration services are a common source of errors in ER hospital visit costs. You can tell if you're being overcharged by checking your medical record.
To verify whether you’re being charged properly, you’ll need your medical record, Fries says. Look for hydration service “start” and “stop” times, which are usually included in the Medication Administration Report (MAR) section of your record. If the hydration service duration is less than 31 minutes of standalone time, you have a strong case to dispute the charge with your hospital. To find out how to get your medical records online, visit our Medical Records guide.
CPT codes are the common language used across all hospitals to describe a certain procedure. They’re what enables our medical coders at Goodbill to analyze hospital bills for errors, line item by line item. They also help us compare prices apples-to-apples across hospitals.
CPT codes are the standard language used to describe a certain procedure across all hospitals. They're key to helping you identify errors or inflated charges in your ER hospital bill.
Unfortunately, the hospital bill you get in the mail is most likely a consolidated summary of your ER visit costs and won’t include CPT codes. You’ll need an “itemized bill” from your hospital to get a line-by-line breakdown of each charge, complete with the CPT code and cost.
The good news is that you’re legally entitled under HIPAA to get access to this information. To learn more about your patient rights and how to obtain your itemized bill, check out our Patient Right of Access guide.
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Itemized bills provide key details that can help you negotiate your hospital bill.
You have time before your bill can go to collections or affect your credit.