How to Set ED Facility E/M Levels for Hospital Claims
A hospital sets its own ED facility levels, using a written internal guideline that relates hospital resources to the five levels. CMS has no national facility scale, and it holds each guideline to 11 principles, which this post turns into a build and test checklist.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: there is no national facility ED level scale. Build a written guideline based on hospital resources, test it against CMS's 11 principles, apply it the same way every time, and keep it ready for audit.
Who Decides the Facility ED Level on a Hospital Claim?
The hospital does, using its own written guideline. Medicare Claims Processing Manual chapter 4, section 160 says CMS believes CPT E/M codes were designed to reflect physician activity, so providers should keep applying their internal guidelines to the existing CPT codes while a national facility set is awaited.
CMS has never published a facility ED level scale in the manual, and this post does not invent one. What it gives you is the standard CMS holds your own guideline to, and the order of work to build, test and defend it. The professional claim is leveled differently, by decision making; see how to pick the right ED E/M level.
Which Codes Carry the Facility Level?
| Department | What it is (chapter 4, section 160) | Codes the hospital bills |
|---|---|---|
| Type A emergency department | Open 24 hours a day, 7 days a week and licensed by the state as an emergency room or department, or held out to the public as a place that treats emergency conditions on an urgent basis without an appointment | The CPT ED visit codes, 99281 to 99285 |
| Type B emergency department | Meets the dedicated emergency department definition in 42 CFR 489.24 | The Type B G-codes, G0380 to G0384 for levels 1 to 5 |
Either way the hospital picks one of five levels from its guideline. The ED facility level coding rule has the background, and CPT 99285 shows the top Type A level.
What Standard Must Your Own Guideline Meet?
Section 160 says each hospital's guideline should follow the intent of the CPT descriptors, relating the intensity of hospital resources to the different levels of effort the five codes represent, and should accurately reflect resource distinctions between the levels. In the CY 2008 OPPS final rule, 72 FR 66580, CMS did not adopt national guidelines and said it would require each hospital's guideline to meet 11 principles.
| Principle (paraphrased from 72 FR 66805) | What to check in yours |
|---|---|
| 1. Follow the intent of the CPT descriptor and relate hospital resources to the levels | Each of the five levels describes a distinct amount of hospital effort |
| 2. Base it on hospital facility resources, not physician resources | The criteria measure what the hospital spent, not what the physician decided. CMS says hospitals may still adapt physician guidelines if they describe hospital resources |
| 3. Be clear enough to support accurate payment, compliance and audits | A reviewer can read it without help |
| 4. Meet HIPAA requirements | Compliance sign-off is on file |
| 5. Require only documentation that is clinically necessary for patient care | No charting added only to reach a level |
| 6. Not facilitate upcoding or gaming | No criterion a department can satisfy without extra resource use |
| 7. Be written or recorded, well documented, and the basis for choosing a code | A dated, versioned document exists |
| 8. Be applied consistently across the patients in the department it covers | The same visit gets the same level whoever codes it |
| 9. Not change with great frequency | CMS expected adjustments less often than every few months, and said annual changes would be reasonable if needed |
| 10. Be readily available for MAC review | You can produce it on request |
| 11. Produce decisions other hospital staff and outside parties can verify | Two coders reach the same level from the same chart |
Principle 11 is the easiest to test yourself. Two coders can read the same chart and reach different levels, so run a blind sample before you rely on the guideline.
How Do You Build or Review the Guideline, Step by Step?
How Does the Facility Visit Appear on the UB-04?
The ED visit goes on its own line under revenue code 045x, and procedures performed in the ER go on their own lines under the same ER revenue code. Section 180.2 of chapter 4 says CMS has required separate charges for the ER visit and for surgical procedures since claims with dates of service on or after July 1, 2001.
Section 180.6 says ER services are reported under the 045x revenue code, and the line item date for the ER encounter is the date the patient entered the ER, even if the encounter spans several dates. Other services in the encounter carry the date they were rendered. See revenue code 0450 and the UB-04 revenue and condition codes rule.
A Type A ED bills a level 3 visit with a laceration repair. The visit line carries modifier 25 because the repair is billed on its own line.
What If the Patient Receives Critical Care?
Section 160.1 applies a 30 minute minimum for 99291, packages 99292 and has the hospital bill an ED visit at its own guideline level when it provides less than 30 minutes of critical care. This is the facility rule, and it differs from the physician side, covered in billing 99285 and 99291 on the same day.
When trauma activation occurs under the NUBC rules, the hospital may also bill one unit of G0390 with a 68x revenue code on the same date, and CMS pays one unit per day. Revenue code series 68x is only for trauma centers designated by the state or local authority, or verified by the American College of Surgeons.
How Do Payers and MACs Test the Level?
Expect CARC 150, which X12 words as the payer deeming that the information submitted does not support this level of service. CMS said in the 2008 final rule it would encourage fiscal intermediaries and MACs to review a hospital's internal guidelines when an audit occurs, so the written guideline is your first exhibit.
- The versioned guideline in force on the date of service.
- The chart elements the guideline counts for that level.
- The blind-sample results that show coders apply it the same way.
- The claim lines, showing the visit and procedures separately.
Check the payer contract and the payer's manual too, in case either states its own facility visit criteria. How ED visits are paid on the outpatient side is covered in how OPPS and APCs pay outpatient claims.
How Does Nucleus Align Handle ED Facility Claims?
Our hospital and facility billing team prepares institutional UB-04 claims with revenue-code validation and checks bill type, revenue codes, patient status, condition and occurrence codes, and payer-specific rules before submission. We work denials within 48 hours. To see how your ED claims hold up, book a call.
- Medicare Claims Processing Manual, chapter 4 (sections 160, 160.1, 180.2, 180.6) · CMS
- CY 2008 OPPS/ASC final rule, 72 FR 66580 · Federal Register
- 42 CFR 489.24 Special responsibilities of Medicare hospitals in emergency cases · eCFR
- Claim adjustment reason codes · X12
We check every rule, code and deadline against the official source. See our editorial policy.
Common Questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How do hospitals set ED facility visit levels?
Each hospital writes its own internal guideline. Medicare Claims Processing Manual chapter 4, section 160 says hospitals should continue applying their guidelines, which should reasonably relate hospital resources to the five levels. CMS did not adopt national facility guidelines in the CY 2008 OPPS final rule.
02Does the facility ED level have to match the physician level?
No. The professional claim is leveled by decision making, and the hospital claim by the hospital's resource guideline. CMS says CPT E/M codes were designed to reflect physician activity, so the two can differ without either being wrong. Each must be supported by its own documentation.
03What codes does a Type B emergency department bill?
Type B departments bill the Type B G-codes instead of the CPT ED codes, G0380 to G0384 for levels 1 to 5. A Type B department is one that meets the dedicated emergency department definition in 42 CFR 489.24. Type A departments bill 99281 to 99285.
04Can a hospital bill 99291 for under 30 minutes of critical care?
No. Chapter 4, section 160.1 says the 30 minute minimum has always applied under OPPS, 99292 is packaged, and a hospital providing less than 30 minutes of critical care bills a visit, typically an ED visit, at the level its own guidelines give.
Talk to a Billing Lead.
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