Silvana Toska was playing in a grass field with her daughters late last fall when she felt a sting on her ankle. The family had come to listen for barred and great horned owls as the sun set on a large park near their Davidson, North Carolina, home.<\/p>\n
It was \u201cjust like a mosquito bite, nothing major, and I just scratched it,\u201d said Toska, a political science professor.<\/p>\n
Then she began to itch everywhere. She couldn\u2019t see anything in the dark, so her husband shined his phone light on her.<\/p>\n
She was covered in hives.<\/p>\n
Because she also felt pressure in her chest, the family quickly went to an urgent care clinic. A doctor there recognized she was experiencing anaphylactic shock<\/a>, a life-threatening, fast-moving allergic reaction.<\/p>\n The doctor rushed her to a room without checking her in, saw her blood pressure was low, and administered two epinephrine injections and IV fluids, Toska said. The itching stopped, and the tightness in her chest went away.<\/p>\n But the doctor said she needed to be monitored in an emergency room for at least two hours in case the reaction flared up again. Toska said the doctor insisted she take an ambulance to a nearby hospital, Atrium Health Lake Norman.<\/p>\n Minutes later, she found herself lying on a stretcher in the ER.<\/p>\n A doctor she described as \u201clovely\u201d came in and spoke to her for no more than five minutes, Toska said. A nurse administered medicine through the IV line inserted at the urgent care clinic.<\/p>\n Toska was exhausted, but her mind was on her daughters. \u201cI had two little kids who were scared, so I was playing with them and trying to distract them.\u201d<\/p>\n After about an hour and a half, the doctor returned briefly, then the family went home, she said.<\/p>\n \u201cThat\u2019s it,\u201d Toska said. \u201cNothing happened at the ER.\u201d<\/p>\n Then the bill came.<\/p>\n Last fall, Toska felt a sting on her ankle while playing in a field with her children. It seemed like \u201cnothing major,\u201d she says. But then Toska began to itch everywhere and discovered she was covered in hives. She also felt pressure in her chest. (A.M. Stewart for KFF Health News)<\/p>\n The Medical Service<\/strong><\/p>\n Toska said the ER doctor reviewed her vitals and discussed her allergic reaction and what to watch for when she got home. She also received a dose of famotidine, a drug often used to treat an upset stomach that is also administered for allergic reactions.<\/p>\n The Bill<\/strong><\/p>\n The in-network hospital system charged Toska\u2019s insurer, Blue Cross Blue Shield of North Carolina, $6,746.50 for the ER visit, including $20.60 for the famotidine and $6,445.60 in \u201ccritical care\u201d charges. Toska, who had not met her insurance deductible, was responsible for a $150 copay and $3,100.24 of the charges.<\/p>\n The Billing Problem: Critical Care<\/strong><\/p>\n \u201cPaying $3,100.24 for literally sitting in the ER entertaining my kids for an hour and a half feels kind of incredible,\u201d Toska said.<\/p>\n Medical providers in the United States use a uniform coding system to bill for procedures and services. Most of Toska\u2019s ER charges stemmed from Atrium Health\u2019s use of two billing codes for \u201ccritical care\u201d \u2014 one for 30 to 74 minutes of care, at $5,617.85 (code 99291), and another for an additional 30 minutes (code 99292), at $827.75.<\/p>\n According to the coding system, critical care is generally defined as<\/a> when a doctor \u201cdirectly\u201d provides at least 30 minutes of care to a patient with \u201ca probability of imminent or life-threatening deterioration.\u201d<\/p>\n According to the ER\u2019s visit notes, which Toska shared with KFF Health News, Toska told the doctor there she was feeling \u201csignificantly better\u201d when she arrived, and the doctor reported providing 90 minutes of personal critical care.<\/p>\n Anaphylactic shock is treated under code 99291, according to the American College of Emergency Physicians coding guidelines<\/a>. Though Toska\u2019s symptoms may have indicated she was no longer in shock, treatment guidelines require at least two hours of monitoring, said Arjun Venkatesh, the chair of emergency medicine at the Yale School of Medicine.<\/p>\n With anaphylaxis, \u201csome people are going to progress and require admission to the ICU, and some won\u2019t,\u201d Venkatesh said.<\/p>\n Toska was under critical care because of what could have happened, not what did happen, Venkatesh said. Hospitals use the same billing codes for the ER visit, whether a patient\u2019s condition deteriorates or not.<\/p>\n \u201cThe billing rules are not built around this,\u201d Venkatesh said.<\/p>\n Laura Eberhard, a spokesperson for Blue Cross Blue Shield of North Carolina, said Toska\u2019s claims \u201cwere submitted by the provider using critical care codes, which represent a higher level of severity and reimbursement, and were processed in-network under the terms of the member\u2019s plan.\u201d She did not answer questions about whether Blue Cross Blue Shield negotiated the charges.<\/p>\n A spokesperson for Atrium Health did not answer questions from KFF Health News about Toska\u2019s visit.<\/p>\n The hospital coded Toska\u2019s ER visit as \u201ccritical care\u201d and charged her insurer more than $6,700. She had to pay more than $3,000. (A.M. Stewart for KFF Health News)<\/p>\n The Resolution<\/strong><\/p>\n Toska said she called Blue Cross Blue Shield of North Carolina, trying to get a better explanation for why the bill for so little hands-on care was so high.<\/p>\n \u201cThe doctor determines the severity of the situation, and that\u2019s the code we have,\u201d the insurance representative said, according to Toska\u2019s recollection. \u201cThis is critical care, and that\u2019s what it costs.\u201d<\/p>\n After Toska contacted the hospital, Atrium Health\u2019s Audit and Appeals Department replied in a letter that the critical care designation was \u201cbased on the presenting problem that brought you to the emergency room, the treatment provided, and the nursing staff that took care of you.\u201d<\/p>\n \u201cIt also includes the room, supplies, and equipment utilized during the visit,\u201d the letter continued. \u201cThe charge is not based on time spent in the facility or with clinicians.\u201d<\/p>\n Asking why the ER visit cost so much was more a matter of principle than necessity, she said, though she thought back a few years to a time when it would have been much harder for her to pay.<\/p>\n \u201cThe system is so broken,\u201d Toska said.<\/p>\n The Takeaway<\/strong><\/p>\n \u201cHer experience is, sadly, very typical,\u201d said Barak Richman, a professor of business law and co-director of the Health Law and Policy program at George Washington University. \u201cOnce you are brought onto the train of health care delivery, you have no control over where the stops are.\u201d<\/p>\n Emergency rooms \u2014 for many the default choice<\/a> for medical care \u2014 are notorious for high costs, he said, adding that insurance companies should always try to negotiate critical care codes.<\/p>\n Toska was fortunate to dodge another problem common in emergencies: The bill for taking an ambulance to the ER was about $275, she said, notable since ambulance rides frequently result in bigger bills<\/a> that may not<\/a> be covered by insurance.<\/p>\n Patients can dispute charges with their insurance and the hospital. Like Toska, they should come to the phone with an itemized bill, medical records, and any other relevant documents, such as explanation-of-benefits statements.<\/p>\n Regardless of whether that\u2019s a fight they can win, some who see one ER bill decide they never want to see another<\/a>, especially if it might put them in medical debt<\/a>.<\/p>\n In early March, Toska had a second allergic reaction. \u201cOK,\u201d she recalled thinking, \u201cDo I go get the EpiPen? Do I go to the ER and get another massive bill?\u201d<\/p>\n She decided against the trip and took Benadryl instead.<\/p>\n Bill of the Month is a crowdsourced investigation by KFF Health News<\/a> and The Washington Post\u2019s Well+Being<\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it<\/a>!<\/em><\/p>\n<\/div>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/em><\/p>\n This <a target=”_blank” href=”https:\/\/kffhealthnews.org\/health-industry\/er-monitoring-anaphylactic-shock-allergic-reaction-bill-of-the-month-april-2026\/”>article<\/a><\/a>; first appeared on <a target=”_blank” href=”https:\/\/kffhealthnews.org”>KFF<\/a> Health News<\/a> and is republished here under a <a target=”_blank” href=”https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/”>Creative<\/a> Commons Attribution-NonCommercial-NoDerivatives 4.0 International License<\/a>.<img src=”https:\/\/kffhealthnews.org\/wp-content\/uploads\/sites\/8\/2023\/04\/kffhealthnews-icon.png?w=150"<\/a>; style=”width:1em;height:1em;margin-left:10px;”><\/p>\n
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