Defending level 4 and 5 ER visits when payers review every one

Why level 4 and 5 are now reviewed by default

Emergency department visits 99281-99285 are leveled by one test: medical decision making. The AMA states that time is not a descriptive component for ED levels, because ED care runs on variable intensity across many patients at once. That leaves the claim's diagnosis codes as the most visible proxy for complexity, and payers have built their review programs on exactly that proxy.

The pattern is now consistent across payer types. A plan compares the diagnosis on a 99284 or 99285 claim with a list it considers low acuity or non-complex. If the diagnosis is on the list, the plan either pays the claim at a lower level automatically, pends it for manual review, or asks for records. Some plans let records restore the billed level; most say a modifier will not.

For an ER group this is not an occasional audit. It is a standing edit that touches the two levels that carry most of the professional revenue. The operating question is no longer whether a payer will review your level 4 and 5 visits but whether your documentation, claim build and appeal routine can win the review at scale.

How the major policies work

The table lists published policies that apply to professional ED E/M claims. Each row is taken from the payer's own policy or provider notice. Our ER payer matrix carries the state-level versions, including Medicaid managed care plans, for all 50 states and DC.

Medicaid managed care runs the same edit

Medicaid managed care plans are often the largest payer in an ER group's book, and several of them run a diagnosis-based leveling edit that predates the commercial wave. The Centene payment policy CC.PP.053, published by Coordinated Care of Washington and other Centene plans, pays a 99284 or 99285 billed with a diagnosis the plan classes as lower complexity at the Level 3 rate. The policy says its coding algorithm was built with a panel of emergency and primary care physicians from a sample of almost 6,000 full ED records, and that a provider may appeal.

Two details in that policy change claim build. First, it reads the primary discharge diagnosis, which it says should be billed in the first diagnosis position. Second, it pays at the Level 3 rate rather than denying, so the adjustment shows up as a lower payment, not a denial, and can pass through posting unnoticed unless someone compares paid level to billed level.

Health Net California applies a sister policy, HNCA.PP.053, but pends the claim and sends written notice that manual review is needed instead of repricing it. Our ER payer matrix lists the Medicaid managed care policy we could verify for each state, so a group working several states can see which plans reprice, which pend and which request records.

What a downcode costs at Medicare rates

Commercial contracts differ, so the cleanest public yardstick is Medicare. Using the CMS October 2026 relative value file, facility total RVUs times the 2026 conversion factor of $33.4009 give these national amounts before geographic adjustment: 99281 $11.02, 99282 $40.42, 99283 $69.47, 99284 $118.24 and 99285 $171.35.

A downcode from 99285 to 99283, the Cigna and Highmark outcome, removes $101.88 per visit at these rates, about 59 percent of the level 5 amount. A 99284 to 99283 adjustment removes $48.77, about 41 percent. Florida Blue's 99285 to 99284 step removes $53.11. Commercial rates are usually higher than Medicare, so the dollar loss on a commercial claim is usually larger, not smaller.

Multiply by volume to size the problem: every 100 level 5 visits paid as level 3 give up $10,188 at these Medicare rates. Price the same count at your own contracted rates for 99285 and 99283 and the figure is the monthly value of the controls below.

The MDM proof a reviewer looks for

MDM has three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity or mortality of patient management. To reach a level, two of the three must be met or exceeded. A reviewer reading a level 5 chart is looking for the two elements that carry it, stated plainly, not inferred from a long note.

The diagnosis on the claim is where most reviews begin, and it is also the most common self-inflicted wound. An ER physician who works up chest pain for acute coronary syndrome, orders troponins and imaging, and discharges with a final diagnosis of chest pain, unspecified, has done high-complexity work and coded a symptom. The final diagnosis is correct, but the claim also needs the presenting problem and the conditions that drove the workup, in the order that tells the story.

• Problems: name the conditions considered and ruled out, not only the final impression. A differential that includes threats to life or bodily function is what supports high complexity.
• Data: list the tests ordered and reviewed, the independent interpretation of an ECG or image, and any discussion with an external physician. Each counts separately.
• Risk: state the decision that carried risk, such as admission considered, parenteral controlled substances, or a decision against escalation, and why.
• Diagnosis order: follow the payer's rule for the first position (Centene CC.PP.053 asks for the primary discharge diagnosis there) and report the conditions evaluated in the positions that follow, so the claim shows why the workup was needed.
• Unique notes: Cigna R36 says cloned or copy-and-paste documentation will not be considered for reimbursement. Templates are fine; identical text across patients is not.
• Signature: an unsigned or draft note cannot support any level; hold it until it is final.

Build the claim so the edit does not fire

Most of these edits read the claim, not the chart. The cheapest defense is a claim that shows the complexity on its face. That means coders who carry the workup diagnoses onto the claim, a pre-submission check that flags any 99284 or 99285 whose only diagnosis is a single symptom or minor condition, and a payer-specific rule set that knows which plans run which edit.

Place of service is the other claim-level control. CMS defines the emergency department as an organized hospital-based facility for unscheduled care, and professional ED codes belong with POS 23. OIG's March 2026 report found Medicare improperly paid physicians $922,524 for 9,749 ED procedure codes billed with a non-ED place of service and asked CMS to recover it. A claim-build check that pairs 99281-99285 with POS 23 removes that exposure entirely.

Critical care is a separate test. Some payers exclude visits with critical care from ED level review; Cigna's R36 lists critical care in the ED among the facility-claim exclusions. Critical care is billed on documented time, not MDM, so when a patient is critically ill, the time statement is what protects the claim.

The appeal file that restores the level

Several policies tell you how to win. Cigna R36 says that if records are submitted that substantiate the medical complexity and MDM, the code will be allowed. Health Net California pends the claim and gives written notice that manual review is needed. Highmark shows billed and adjusted codes on the explanation of payment. Each of these is an invitation to send the right record, quickly, in a standard format.

• Pull adjusted claims weekly from the remit, by payer and by CARC, and separate downcodes from denials. A level change paid at a lower amount is easy to miss in posting.
• Score each one: does the chart meet two of three MDM elements for the billed level? Appeal those that do; accept and learn from those that do not.
• Build a one-page summary on top of the note: problems addressed, data reviewed with each test named, risk decision, and the policy section the payer cited.
• Send within the payer's appeal window and track the outcome as its own denial category so the overturn rate is visible.
• Feed lost appeals back to the physician with the specific missing element; that is where the next month's downcodes are prevented.

A 30-day rollout for an ER group

None of this needs new software to start. It needs a list, a rule set and a weekly habit. This is the order we use when we take on an ER group's level review problem.

• Week 1: list every payer in the book that runs a published ED leveling policy, with the trigger, the outcome and the appeal route, starting from the table above and the state matrix.
• Week 1: pull the last 90 days of remits and mark every 99284 and 99285 line paid at a lower level, by payer and by physician. This is the baseline.
• Week 2: add two pre-submission checks: 99281-99285 must carry POS 23, and any 99284 or 99285 with a single symptom or minor diagnosis goes to a coder before it is released.
• Week 2: agree a one-page appeal summary format with the physicians, so records go out with the MDM elements already laid out.
• Week 3: appeal the baseline downcodes that meet two of three MDM elements, oldest first so none miss the payer's window.
• Week 4: share level 4 and 5 rates and downcode results with each physician, alongside peers, with specific examples of what the reviewer found missing.
• From then on: run the scorecard below every month and recheck payer policies each quarter, since several of these were issued or updated in 2026.

Measure it like a denial program

Treat level reviews as a measured stream, not background noise. Five numbers tell you whether the program is working: the share of ED visits billed at level 4 and 5 by physician, the downcode rate by payer, the dollar value of downcodes at your contracted rates, the appeal rate on downcodes that meet MDM, and the overturn rate. A physician whose level 5 share sits far above peers with a similar case mix needs education; a payer whose downcode rate rises after a policy change needs an appeal campaign and, if the pattern holds, a contract conversation.

OIG also has an active audit series on Medicare ED E/M services, with projects announced in 2021 and 2024, that will determine whether payments for ED E/M services were appropriate and medically necessary. The same documentation that wins a commercial appeal is what a Medicare reviewer will ask for, so the controls in this guide serve both.