Emergency medicine billing services
Professional billing for emergency physician groups, with ED levels, critical care and procedures coded from the chart and out-of-network claims handled correctly.
Why emergency medicine billing takes specialty knowledge
Emergency physicians see every payer and every kind of patient, often without an insurance card in hand. ED visit levels 99281-99285 are chosen by medical decision making only, since time does not count for these codes. Critical care is billed by time and has different counting rules for Medicare and CPT. Procedures, ECG reads and observation stays can all happen during one encounter, and many emergency groups are out of network with at least some plans.
SFA Solutions codes emergency claims from the full ED record. We level visits by MDM, total critical care minutes correctly, add procedures with modifier 25 where needed, and track demographic and insurance updates from the facility so fewer claims are held for missing information. For out-of-network claims, we follow No Surprises Act rules for patient cost sharing and use open negotiation and independent dispute resolution when payments come in low.
Common codes we work with in emergency medicine
| Code | Description |
|---|---|
| 99283 | Emergency department visit, low medical decision making |
| 99284 | Emergency department visit, moderate medical decision making |
| 99285 | Emergency department visit, high medical decision making |
| 99291 | Critical care, first 30 to 74 minutes |
| 99292 | Critical care, each additional 30 minutes |
| 93010 | Electrocardiogram interpretation and report only |
| 12002 | Simple repair of superficial wounds of scalp, neck, trunk or extremities, 2.6 to 7.5 cm |
| 31500 | Emergency endotracheal intubation |
CPT is a registered trademark of the American Medical Association. Payer rules vary; we check each payer's current policy.
Where emergency medicine practices lose revenue
ED levels by medical decision making
Since 2023, ED visits 99281-99285 are leveled by MDM alone: the number and complexity of problems, the data reviewed and ordered, and the risk of management. Time is not used. Payers increasingly review and downcode level 5 visits, so documentation must clearly support high MDM, including decisions about hospitalization and independent test interpretation.
Critical care time
99291 covers the first 30 to 74 minutes of critical care, and 99292 covers each additional 30 minutes. Medicare requires 104 total minutes before 99292 can be billed, while CPT counts it from 75 minutes. Time spent on separately billed procedures cannot be counted toward critical care time, and the note must state total time.
Procedures and interpretations
Laceration repairs, splinting, intubation and other procedures are billed in addition to the ED visit, with modifier 25 on the E/M when required. ECG interpretations are billed with 93010 when the emergency physician provides the documented interpretation. Only one physician can be paid for interpreting the same study.
Out-of-network claims and the No Surprises Act
For emergency services, patients pay no more than their in-network cost sharing, and out-of-network providers cannot balance bill them for covered services. Payment disputes with health plans go through a 30-day open negotiation period and then federal independent dispute resolution. Deadlines are strict, so tracking each initial payment date matters.
What else affects emergency medicine revenue
A/R challenges in emergency medicine
Under EMTALA, emergency physicians treat patients before insurance is confirmed, so many ED claims start as self-pay or with incomplete demographics from registration. Some of those patients later qualify for Medicaid, which can cover care retroactively for up to three months before the application month in most states, so self-pay accounts should be rechecked before they go to patient statements. Out-of-network balances follow No Surprises Act timelines, and missed open negotiation or IDR deadlines are a common reason these accounts stall.
Credentialing considerations
Emergency groups add physicians, PAs, NPs and locum providers often, and each one needs payer enrollment and reassignment to the group before their claims can be paid under the group contract. Emergency medicine physicians enroll under taxonomy 207P00000X, and hospital privileges must be in place at each facility the group staffs. When a group takes over a new hospital contract, enrollment for the whole roster has to be started early so there is no gap in billable dates.
Payer considerations
Under the ACA's prudent layperson standard, most health plans must decide emergency coverage based on the patient's symptoms, not only the final diagnosis, and that standard is the basis for appealing many ED denials. Some commercial and Medicaid managed care plans run automated review that downcodes level 4 and 5 visits, which calls for appeals with the full chart. Medicare Advantage plans cannot require prior authorization for emergency services, so denials on that basis should be challenged.
Emergency Medicine coding details that affect payment
ICD-10 considerations
ED claims are coded from the final clinical impression, and when no definitive diagnosis is reached, sign and symptom codes such as R07.9 (chest pain, unspecified) or R10.9 (unspecified abdominal pain) are correct. Listing the presenting symptoms also supports appeals under the prudent layperson standard when the final diagnosis turns out minor. Injury codes need a 7th character (A for the initial encounter in active treatment), laterality, and external cause codes for mechanism and place where payers or state reporting require them. Poisoning codes in T36 to T50 combine the substance and intent in one code, so the record has to state whether the event was accidental, intentional or an adverse effect.
Modifiers to watch
| FT | Used by Medicare on critical care provided on the same day as a procedure with a global period when the critical care is unrelated to that procedure. |
|---|---|
| 54 | Added when the ED physician performs fracture care such as a closed reduction but the follow-up care will be handled by orthopedics. |
| 26 | Applied when the emergency physician provides the formal interpretation of an X-ray or CT and the payer recognizes ED physician reads. |
| 59 or XU | Used when a separate procedure, such as a second laceration repair at a distinct site, would otherwise be bundled by NCCI. |
| FS | Required by Medicare on split or shared ED visits where a physician and an NP or PA both see the patient and the practitioner who did the substantive portion bills. |
Global periods
Most ED procedures, including laceration repairs 12001 to 12007, carry 0-day globals. Fracture care codes often carry 90-day globals, so ED physicians who do not provide the follow-up usually bill with modifier 54 so the treating orthopedist can bill the postoperative care.
Medicare considerations
Medicare pays split or shared ED visits to the practitioner who performed the substantive portion, with modifier FS, and NP or PA services billed under their own NPI are paid at 85% of the physician fee schedule. Patients placed in observation and discharged the same day are billed with 99234 to 99236 instead of an ED code by the admitting practitioner. Medicare Advantage plans must follow the prudent layperson standard for emergency services.
Emergency Medicine billing KPIs to track
- E/M level distribution. Comparing your share of 99284 and 99285 to peer benchmarks shows both undercoding and audit risk.
- Self-pay to insured conversion rate. EMTALA means many patients arrive without coverage, so finding insurance before statements go out recovers revenue.
- Chart lag days. ED groups wait on facility records, and days from service to charge entry is often the largest driver of A/R.
- IDR deadline compliance. Missed open negotiation or IDR deadlines forfeit the right to dispute low out-of-network payments.
Emergency Medicine billing audit checklist
- Review a sample of level 5 visits for documentation of high complexity medical decision making.
- Confirm critical care notes state total time and exclude time spent on separately billed procedures.
- Check that injury claims carry a valid 7th character and laterality.
- Verify ECG and imaging interpretation claims are not duplicated with another physician's read.
- Match self-pay accounts against eligibility and Medicaid retroactive coverage before patient statements.
- Confirm split or shared visits identify the practitioner who performed the substantive portion.
How SFA runs emergency medicine billing
We receive ED charts and facility face sheets daily and confirm patient insurance information.
Coders level visits by MDM, total critical care time and add procedures and interpretations.
Claims are reviewed against payer rules, with a 24-hour target for submitting clean claims once complete records are in.
Downcodes and low out-of-network payments are appealed or taken to negotiation within the required deadlines.
The services that matter most for emergency medicine
Medical Coding
ED levels, critical care time and procedures must be coded from detailed charts to hold up against downcoding.
Learn moreDenial Management
Downcoded level 5 visits and out-of-network underpayments often need formal appeals or dispute resolution.
Learn moreA/R Recovery
ED claims frequently start with incomplete insurance information, so older balances need persistent follow-up.
Learn moreWhat practices typically see with SFA
Averages and selected client results. Your free audit shows where your own numbers stand today.
Target for the claims we manage, not a measured average.
Highest improvement seen in selected client results.
Largest drop in A/R days seen in selected client results.
Targeted for submission within 24 hours after final review.
From primary care and nurse practitioners to surgery and imaging.
We work inside the system your practice already uses.
Results vary by practice, specialty, payer mix, claim volume, billing history, documentation and other factors. Performance figures represent average or selected client results and are not guarantees of future performance. The 95% figure is a clean-claim target, not a measured cohort. The client-results page does not include a measurement period, starting collections, or practice size.
Emergency Medicine billing questions
Does time count for ED visit levels?
No. ED codes 99281-99285 are selected by medical decision making only. Time can be used for critical care, which is billed with 99291 and 99292.
Can I bill critical care and an ED visit on the same day?
Yes, when the ED visit happened before the patient became critically ill and the critical care was a separate service. Append modifier 25 to the ED visit and document both services and the critical care time.
How does the No Surprises Act affect emergency physician billing?
Patients pay only their in-network cost sharing for emergency services and cannot be balance billed for covered services. If the plan's payment is too low, you can start open negotiation and then federal independent dispute resolution.
Can the ED physician bill an ECG read?
Yes, with 93010 when the physician documents a separate interpretation and report. If another physician, such as a cardiologist, is paid for the same read, the second claim is usually denied.
How do you handle patients who arrive without insurance information?
We work with the facility's registration data, run eligibility searches and update coverage as it is found before billing the patient directly.
See what your emergency medicine billing is missing
Send us a few details and an RCM specialist who knows emergency medicine will review where claims are denied, underpaid or left unbilled.
- A clear walkthrough of what we find
- Reply typically within one business day
- No commitment
Request your free practice audit
An RCM specialist typically replies within one business day.