Emergency department billing services, read like a monitor strip.

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.

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.

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.

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.

Each state’s Part B contractor is in the Medicare column of the matrix above, taken from CMS’s own jurisdiction pages.

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.

Every emergency visit produces two claims. The hospital bills the facility claim for the room, nursing, supplies and drugs, and levels that visit with its own internal guidelines, which CMS requires to reflect hospital resource use rather than physician work. The emergency physician or group bills the professional claim for the clinician's work using CPT 99281 to 99285, critical care and procedure codes. We bill the professional side and reconcile it against the facility record so both tell the same story.

Since January 2023 the level of an emergency department visit is based on medical decision making alone. CPT scores MDM on the number and complexity of problems addressed, the data reviewed and analyzed, and the risk of the management decisions. History and exam no longer determine the level, although both must still be medically appropriate, and time cannot be used because ED visits are untimed services. Our coders score each chart on those elements and note why the level is supported.

CPT 99291 applies when the emergency physician personally delivers at least 30 minutes of critical care to a patient with acute impairment of one or more vital organ systems and a probability of imminent, life-threatening deterioration. Report 99291 once per date for 30 to 74 minutes, even if the time is not continuous. For Medicare, 99292 is added only when total time reaches 104 minutes, then for each further full 30 minutes. Time spent on separately billed procedures is excluded, and if an ED visit preceded the critical care it must be documented as separate and distinct.

Yes. When an emergency physician performs a procedure such as a laceration repair, fracture care or incision and drainage and also provides a significant, separately identifiable E/M service on the same day, the ED visit code is reported with modifier 25. Medicare does not require a different diagnosis, but the record must show E/M work above and beyond the usual pre and post procedure work. Modifier 25 is also used when a separate E/M visit precedes critical care on the same date.

For patients in employer, individual market and federal plans, emergency services must be covered without prior authorization and regardless of whether the physician or facility is in network. Patient cost sharing is limited to in-network levels, and the out-of-network provider cannot balance bill for emergency care, including post-stabilization services unless specific conditions are met. The plan pays an initial amount or denies, and any disagreement over the amount moves to open negotiation and then the federal IDR process.

Federal independent dispute resolution is the No Surprises Act route for settling what a plan pays an out-of-network emergency provider when the two sides disagree. After the initial payment or denial, either party opens a 30 business day negotiation. If that fails, the dispute must be started within 4 business days through the federal IDR portal, a certified IDR entity is selected, each side submits one offer and the entity picks one. The decision binds both parties. The operating rules changed in 2026, so check deadlines and fees at filing.

There is no single answer, but the rules set outer bounds. Medicare requires claims to be filed within one calendar year of the date of service, and state Medicaid agencies must pay 90 percent of clean claims within 30 days and 99 percent within 90 days. Commercial plans follow state prompt pay laws. Clean electronic ER claims usually pay within weeks; the delays come from eligibility errors, missing records, prudent layperson reviews and out-of-network disputes, which is what our front-end work is designed to prevent.

The denials we see most often in emergency medicine fall into a few groups: eligibility and coverage errors at registration, missing notification for patients who are admitted, level of care disputes on 99284 and 99285, diagnosis-based denials that ignore the prudent layperson standard, bundling edits on procedures billed with E/M codes, timely filing, and out-of-network payment disputes. Most are preventable with clean registration, MDM-based coding and modifier discipline, and the rest are appealable with the right record.

The prudent layperson standard defines an emergency by the symptoms the patient had on arrival, not by the final diagnosis. Under federal Medicaid managed care rules an emergency medical condition is one with acute symptoms, including severe pain, severe enough that a person with average knowledge of health and medicine could reasonably expect serious harm without immediate care, and plans may not limit emergencies to lists of diagnoses. We cite this standard when a payer downcodes or denies a visit because the discharge diagnosis looked minor.

Yes, in two ways. EMTALA requires Medicare participating hospitals with emergency departments to provide a medical screening examination and stabilizing treatment when a request is made, regardless of ability to pay, so registration cannot delay care to verify insurance or collect money. Billing data is therefore often incomplete at the point of service and has to be captured afterwards. EMTALA does not prevent billing for the screening and treatment; it governs when financial questions can be asked.

Since 2023 observation and inpatient visits share one code family: 99221 to 99223 for initial care, 99231 to 99236 for subsequent care and same day admission and discharge, and 99238 and 99239 for discharge. Only the treating practitioner who admits and manages the observation stay bills those codes, one code per calendar date. An emergency physician who evaluates and hands off bills the ED visit; a hospitalist, or an ED group that runs its own observation unit, bills the observation codes.

Yes. Medicare calls this a split or shared visit and allows it in facility settings, including the emergency department, when a physician and a non-physician practitioner from the same group both see the patient. Since January 2024 the practitioner who performs the substantive portion, meaning more than half of the total time or the substantive part of medical decision making, bills the visit with modifier FS. The record must identify both practitioners and be signed by the one who bills. Commercial payers may apply their own rules.

Outsourcing makes sense when an emergency group cannot keep coders current on MDM rules, critical care time and No Surprises Act disputes, when denials and receivables over 90 days are growing, or when leaders want their time back for staffing and contracts. It makes less sense when the group already has a stable, well-measured in-house team. The honest test is numbers: coding accuracy, clean claim rate, days in A/R and net collection rate. We benchmark those first and only propose a change if the gap is real.

An emergency department billing company turns ED charts into paid professional claims. The work covers demographic and insurance capture after the visit, coding each chart for E/M level, critical care, procedures and modifiers, charge entry, claim scrubbing and submission, payment posting, denial and appeal management, No Surprises Act negotiation and IDR filings, patient statements, payer credentialing and reporting. The better companies also feed documentation findings back to the physicians so every level is defensible on audit.