Virginia emergency department billing services
Professional ER billing for emergency medicine groups in Virginia: MDM-based 99281-99285 levels, critical care time, modifier 25, payer enrollment and No Surprises Act claims, built on the Virginia payer rules verified below.
What changes an ER claim in Virginia.
Every Virginia rule on file, each linked to its primary source: state surprise-billing law, Medicaid ER policy, Medicaid managed care, the Blue plan and the Medicare contractor.
| Rule type | Date | What it says | Source |
|---|---|---|---|
| State surprise-billing law | Jan 2021 | Va. Code 38.2-3445.01 bans balance billing for out-of-network emergency services. Carrier must offer a commercially reasonable amount (same/similar services, similar area) within 30 days of a clean claim; 30-day dispute and 30-day negotiation windows, then arbitration under 38.2-3445.02. | Source |
| Medicaid ER policy | Apr 2023 | Virginia Medicaid ended ER downcoding: from DOS 4/27/2023, DMAS and its MCOs no longer cut 99282-99284 claims with a preventable-ER diagnosis to the 99281 rate (court order). Claims from 4/27/2023 are reprocessed automatically; no resubmission needed. | Source |
| Medicaid managed care | Nov 2026 | Anthem HealthKeepers Plus (VA Medicaid): for claims processed from 11/1/2026, an E&M billed with an XXX-global procedure (injections, infusions) must carry modifier 25 to pay; from 12/1/2026 modifier-25 claims are reviewed for a significant, separately identifiable E&M. | Source |
| Blue plan | Nov 2026 | Anthem BCBS Virginia (commercial): from claims processed 11/1/2026, E/M billed with XXX-global procedures (injections, infusions) needs modifier 25 to pay; from 1/1/2027 Anthem reviews modifier-25 E/M documentation and may deny or require corrected claims. | Source |
| Medicare contractor | Jul 2026 | Medicare Part B ER claims in Virginia go to Palmetto GBA, A/B MAC Jurisdiction M (JM), except Arlington and Fairfax counties and the City of Alexandria, which CMS assigns to Jurisdiction L (Novitas) for Part B. | Source |
How we bill Virginia ER visits.
The same four-step workflow we run for emergency medicine and hospitalist groups billing from their hospital system.
Hospital feed and registration
Demographics, insurance and the attending physician arrive from the hospital system daily. Gaps go back to registration as clarification requests, not guesses.
MDM levels and critical care minutes
ED visits 99281-99285 are coded on medical decision making only. Critical care is 99291 for 30 to 74 minutes and 99292 from 104 total minutes, on documented time.
Modifier 25 and enrollment check
A separately identifiable E/M on the day of a procedure carries modifier 25 with its own documentation. The rendering physician is checked against the payer roster before release.
Submission, remit and NSA/IDR
Professional claims go out with place of service 23. Out-of-network ER claims follow the No Surprises Act: in-network cost share only, open negotiation, then federal IDR.
FAQ: ER billing in Virginia.
Does Virginia have a state surprise billing law for ER care?
Va. Code 38.2-3445.01 bans balance billing for out-of-network emergency services. Carrier must offer a commercially reasonable amount (same/similar services, similar area) within 30 days of a clean claim; 30-day dispute and 30-day negotiation windows, then arbitration under 38.2-3445.02.
What does Virginia Medicaid require for ED visits?
Virginia Medicaid ended ER downcoding: from DOS 4/27/2023, DMAS and its MCOs no longer cut 99282-99284 claims with a preventable-ER diagnosis to the 99281 rate (court order). Claims from 4/27/2023 are reprocessed automatically; no resubmission needed.
How do Virginia Medicaid managed care plans handle ER claims?
Anthem HealthKeepers Plus (VA Medicaid): for claims processed from 11/1/2026, an E&M billed with an XXX-global procedure (injections, infusions) must carry modifier 25 to pay; from 12/1/2026 modifier-25 claims are reviewed for a significant, separately identifiable E&M.
What is the Virginia Blue plan policy on ER claims?
Anthem BCBS Virginia (commercial): from claims processed 11/1/2026, E/M billed with XXX-global procedures (injections, infusions) needs modifier 25 to pay; from 1/1/2027 Anthem reviews modifier-25 E/M documentation and may deny or require corrected claims.
Which Medicare contractor processes Virginia ER professional claims?
Medicare Part B ER claims in Virginia go to Palmetto GBA, A/B MAC Jurisdiction M (JM), except Arlington and Fairfax counties and the City of Alexandria, which CMS assigns to Jurisdiction L (Novitas) for Part B.
Nearby ER billing state guides.
Neighbouring state pages with their own verified ER payer rules.