Emergency department billing & RCM
Emergency department billing services, read like a monitor strip.
Professional billing for ER and hospitalist groups: charge capture from the hospital feed, MDM-based levels, critical care minutes, payer enrollment and No Surprises Act claims, with a senior partner on every account.
ED visit levels
Five levels, one test: medical decision making.
The AMA descriptors set each ED level by MDM alone. Payers police the top two, so 99284 and 99285 need the problems, data and risk written into the note.
What payers do with 99284 and 99285
- Cigna commercial R36 (updated Feb 13, 2026): professional ED claims for 99284/99285 with a single non-complex diagnosis are paid as 99283; a modifier does not override; records showing MDM complexity restore the billed level. Cloned notes not accepted. source
- Aetna (commercial, Medicare, Student Health) from July 8, 2024 reviews physician and facility ER claims billed at level 4 or 5 E&M and may adjust payment when claim details do not support the level; covers fully and self-insured plans (WA and TX fully insured timing set separately). source
- UnitedHealthcare Commercial/Exchange professional E/M policy 2026R5007A (reviewed Apr 1, 2026): 99281-99285 leveled by MDM only, only in a CPT-defined ED (incl. hospital-owned freestanding EDs); ED levels may be adjusted or denied if documentation falls short. source
- Pennsylvania. Highmark (PA, DE, WV) from 30 Mar 2026 reviews professional ED claims billed 99284/99285; low-acuity non-emergent visits (Mercer LANE list) are auto-downcoded to 99283. EOP shows billed and adjusted codes. See RP-037. source
- Florida. Florida Blue policy 26-088 (eff. 1 Jun 2026, commercial and MA, CMS-1500): 99285 billed with a diagnosis on its low-acuity non-emergent list is repriced to 99284. Excludes patients under 2, hospital-billed ED E/M and Medicare-primary. Appeal with records. source
Critical care
Critical care runs on the clock, not on complexity.
Medicare counts total critical care minutes on a date. The first unit of 99291 needs 30 minutes; the first 99292 needs 104.
One unit of 99291, billed once per date even if the time is not continuous.
74 plus a full 30. Below 104, Medicare pays 99291 only.
A second 99292 for the next full 30 minutes, and so on.
Split or shared critical care goes to the practitioner with more than half the total time.
The ER claim, end to end
From the triage desk to the remit, in seven beats.
Each beat is where an ER claim either keeps its value or loses it.
Arrival
EMTALA screen firstThe hospital must screen and stabilise regardless of ability to pay, so coverage is often unknown when the patient is seen.
Registration
From the hospital feedDemographics, insurance and the attending arrive from the hospital system. Gaps go back to registration, not into a guess.
Documentation
Signed chartDraft or unsigned notes are held and chased by physician name. Nothing is coded from an incomplete record.
Coding
MDM for visits, minutes for critical careED levels come from medical decision making; critical care comes from documented time. They never borrow each other’s basis.
Enrollment
Roster check per payerA claim for a physician not yet effective with that payer is held and routed instead of becoming an enrollment denial.
Submission
837P, POS 23Professional ED claims go out with place of service 23. OIG found $922,524 Medicare paid on ED codes billed with another POS.
Payment
Remit, review, IDRLevel 4 and 5 visits draw payer review. Out-of-network ER claims follow the No Surprises Act: open negotiation, then federal IDR.
The rules that decide payment
Six rules every ER claim answers to.
Each one is from CMS or the AMA; sources are listed at the end of the page.
ED visits are leveled by medical decision making only
CMS: for emergency department visits practitioners use MDM, not time, so the note must carry problems addressed, data reviewed and risk.
Critical care is billed on time only
99291 covers 30 to 74 minutes on a date. For Medicare, 99292 starts only at 104 total minutes. Start, stop and the critical care statement belong in the record.
Split or shared critical care
The practitioner with more than half of the total time bills it, with modifier FS on the claim.
Modifier 25 with a same-day procedure
A significant, separately identifiable E/M on the day of a laceration repair or fracture care needs its own documentation and modifier 25.
No Surprises Act for emergency care
Out-of-network emergency providers cannot bill covered patients beyond in-network cost sharing; notice and consent does not apply to emergency medicine.
EMTALA means coverage is found after the visit
Eligibility checks, insurance discovery and registration clarifications after the visit decide how much of the ER book is billable.
Related: split/shared visits in 2026 · No Surprises Act IDR rule · modifier 25 · insurance discovery
State-by-state ER payer matrix
The ER payer matrix, 50 states and DC.
State surprise-billing law, Medicaid ER policy, Medicaid managed care, the state’s Blue plan and the Medicare contractor. 184 rules, each re-checked against its primary source on October 3, 2026. A blank means we could not verify a rule, not that none exists.
| State | State surprise-billing law | Medicaid ER policy | Medicaid managed care | Blue plan | Medicare contractor |
|---|
National rules and payers
What changed for ER groups nationally.
Federal rules and national payer policies that apply in every state, newest first.
How we run ER billing
The workflow we run today for an ER group.
For an emergency medicine and hospitalist group billing from its hospital’s system.
Daily hospital feed intake
Registration, insurance and attending come in every day; gaps go back to hospital registration as clarification requests.
Coding from the signed chart
ED visits on MDM, critical care on documented time; unsigned notes held and chased by physician.
Enrollment-aware release
Rendering physician checked against the payer roster before the claim leaves.
Submission and follow-up
Claims through the clearinghouse; rejections and denials worked daily by cause.
Weekly governance
The group sees registered, coded, held and paid each week, holds by physician and denials by cause.
Quick reference
ER codes and modifiers at a glance.
| Code | What it is | Billing rule |
|---|---|---|
| 99281-99285 | Emergency department visits | Level set by MDM; time does not count. |
| 99291 | Critical care, first 30-74 minutes | Once per date; time-based only. |
| 99292 | Critical care, each additional 30 minutes | Medicare: from 104 total minutes. |
| Modifier 25 | Separately identifiable E/M with a procedure | Own documentation, same day. |
| Modifier FS | Split (or shared) visit | Billed by the practitioner with the substantive portion. |
| POS 23 | Emergency room, hospital | Place of service for professional ED claims. |
Enrollment matters as much as coding in the ER: see medical credentialing services. Hospital-side work: hospital revenue cycle. Walk-in clinics: urgent care billing services.
Questions
Questions ER groups ask.
Can emergency department visits be leveled by time?
No. CMS states that for emergency department visits practitioners use medical decision making, not time, to select 99281-99285. Critical care is the opposite: it is billed on time only.
When can 99292 be billed to Medicare?
Under the Medicare Claims Processing Manual, 99291 covers 30 to 74 minutes on a date, and 99292 can be reported only when a further full 30 minutes is furnished, which is 104 total minutes.
Do payers downcode 99284 and 99285?
Several do, by written policy. Cigna pays professional 99284/99285 claims with a single non-complex diagnosis as 99283; Aetna reviews level 4 and 5 ER claims; several Blue plans and Medicaid plans have similar edits. The state matrix on this page lists each one with its source.
Can an out-of-network ER physician bill the patient for the balance?
Not for covered emergency services. Under the No Surprises Act, out-of-network providers of emergency services cannot bill the patient more than in-network cost sharing, and the notice-and-consent exception does not apply to emergency medicine.
Which Medicare contractor processes my state’s ER claims?
Each state’s Part B contractor is in the Medicare column of the matrix above, taken from CMS’s own jurisdiction pages.
Do we have to change systems to work with you?
No. We work from the hospital feed and the chart you already use, and submit through a clearinghouse. Your physicians keep documenting where they do today.
Sources
- CMS, Medicare Claims Processing Manual, Chapter 12 (30.6.1, 30.6.11, 30.6.12)
- AMA, 2023 E/M descriptors and guidelines (99281-99285)
- CMS, FAQs for providers about the No Surprises rules
- CMS, No Surprises: understand your rights against surprise medical bills
- CMS, Emergency Medical Treatment and Labor Act (EMTALA)
- State, payer and federal sources for every matrix cell
Checked October 3, 2026. Rules change; confirm against the source before relying on them.
Free 30-day audit for ER physician groups.
Send us 90 days of ER claims. We check levels, critical care capture, enrollment holds and denials, and give you a written report.