Emergency Department E/M Coding

ED E/M Coding Overview

Emergency department visits use dedicated E/M codes 99281-99285, separate from office visit codes. Code selection is based on medical decision-making complexity. ED visits do not distinguish between new and established patients — the same code set applies to all ED encounters. 99283 (moderate complexity) and 99284 (moderate-to-high) account for approximately 60% of all ED claims nationally.

Code Selection by Severity

  1. 99281 (Straightforward): Minor problem, minimal workup. Insect bite, prescription refill. Reimburses $25-$50.
  2. 99282 (Low): Low-complexity problem requiring limited workup. Simple laceration, minor sprain. Reimburses $50-$90.
  3. 99283 (Moderate): Moderate-complexity problem. UTI, asthma exacerbation, uncomplicated fracture. Reimburses $100-$170.
  4. 99284 (Moderate-High): Significant problem with uncertain diagnosis or treatment. Chest pain workup, abdominal pain with imaging. Reimburses $170-$280.
  5. 99285 (High): Life-threatening or severe problem. Acute MI, stroke, major trauma, respiratory failure. Reimburses $280-$450.

Critical Care Billing

When a patient requires critical care (direct personal management of life-threatening conditions), bill 99291 (first 30-74 minutes) and 99292 (each additional 30 minutes). Critical care replaces the ED E/M code — do not bill both. Critical care time includes only time spent at the bedside or in direct management. Charting, family discussions about prognosis, and coordination with admitting teams all count toward critical care time. Document start and stop times.

Common Denials

CO-45 (exceeds fee schedule) when the E/M level does not match the documented complexity. CO-16 when the procedure code conflicts with the E/M level (e.g., 99285 with a minor diagnosis code). CO-97 bundling when procedures are not separated from the ED E/M. CO-11 (medical necessity) when the visit does not meet emergency criteria. See EMTALA billing rules for medical screening exam requirements.

Common Questions About ED Coding

Can I bill an ED visit and critical care on the same encounter?

No. If the patient's condition escalates to critical care during the ED visit, bill critical care codes (99291/99292) for the total qualifying time. The initial ED evaluation is included in the critical care time. Do not bill 99284/99285 in addition to 99291.

How do I code an ED visit that results in admission?

The ED physician bills the ED E/M code (99281-99285). The admitting physician bills the initial hospital care code (99221-99223). Both services are billable on the same date because they are provided by different physicians with different roles. The ED physician does not bill an admission code.

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This reference is for informational purposes. Always verify against current payer policies, CPT guidelines, and CMS documentation. Last updated: 2026-04-06.