Emergency department billing company for EDs and freestanding ERs

What makes emergency department billing hard?

Emergency billing is hard because one visit produces at least two claims, and each follows different rules. The hospital bills its facility charges on the UB-04, while the emergency physicians bill their professional work on the CMS-1500. The two levels are set by different people using different criteria.

Payer behavior adds a third layer. Many emergency visits are out-of-network, and insurers pay them by their own formula. Medicare, in its own Claims Processing Manual, says CPT E/M codes were built around physician work and do not describe well the mix of services a hospital provides in an ED visit. That is why the facility level and the physician level are set separately.

How are ED physician visits coded: 99281 to 99285 and critical care 99291?

Emergency physicians report one of five ED E/M codes, 99281 through 99285, or critical care code 99291 when the patient is critically ill. The level of an ED visit rests on medical decision making, and a medically appropriate history and exam must be documented but no longer set the level. CMS confirmed this for 2023 in its MLN summary MM12982 of the CY 2023 Physician Fee Schedule final rule.

CPT descriptors belong to the AMA, so the table below describes the codes in our own words. Always read the current CPT book for the exact wording.

Critical care has its own rules in Medicare. Under Medicare Claims Processing Manual Chapter 12, section 30.6.12.2, a practitioner reports 99291 once per date, even if the time is not continuous, and non-continuous time can be added together.

Another E/M visit on the same date as critical care is billable only when three things are documented: it happened before the patient needed critical care, it was medically necessary, and it was separate from the critical care work. Chapter 12, section 30.6.12.6, also requires modifier 25 on the critical care claim in that case.

Chapter 12, section 30.6.11, adds rules specific to who can use the ED codes. Any physician seeing a patient registered in the ED can use them, and the physician need not be assigned to the ED. If a physician asks a patient to meet in the ED as an alternative to the office and the patient is not registered there, the visit is billed with office or outpatient codes. If a second physician evaluates the patient and admits them, that physician bills initial hospital care and not an ED visit code.

How do hospitals set the facility ED visit level?

A hospital sets facility ED levels through its own written guidelines, not through the physician's code. CMS tells hospitals to apply internal guidelines that follow the intent of the CPT descriptors and relate the intensity of hospital resources to the five levels. Medicare Claims Processing Manual Chapter 4, section 160, says each hospital's guidelines should reflect real resource differences between the levels.

The type of ED decides which codes go on the claim. Chapter 4, section 160, says visits in a Type A emergency department are billed with CPT ED codes, and visits in a Type B emergency department are billed with HCPCS G-codes G0380 through G0384.

Critical care on the facility side follows OPPS rules. Chapter 4, section 160.1, says 99291 means at least 30 minutes of active, face-to-face critical care by the physician or hospital staff, and 99292 is packaged. If a hospital provides less than 30 minutes, it bills a visit, typically an ED visit, at a level consistent with its own internal guidelines.

Verify these rules on the CMS OPPS pages before building edits around them, because the manual shows its own revision dates. For the claim itself, see our hospital and facility billing service, which covers the UB-04 checks for emergency care.

How does EMTALA affect billing?

EMTALA requires a participating hospital to give an appropriate medical screening exam to anyone who comes to its emergency department, and billing has no say in that. Under 42 CFR 489.24(a)(1)(i), the exam must be within the capability of the hospital's emergency department.

Section 489.24(d)(4)(i) says a participating hospital may not delay the screening exam to ask about method of payment or insurance status. A payer question cannot hold up the exam. If an emergency condition exists, the hospital must also provide necessary stabilizing treatment or an appropriate transfer under paragraph (a)(1)(ii).

The rule reaches beyond the main ED building. Section 489.24(b) defines a dedicated emergency department as one that is state licensed as an emergency room, held out to the public as providing emergency care, or that provides at least one-third of its outpatient visits for emergency conditions. The same definition feeds CMS's Type B category above. Our EMTALA and billing rule page goes through documentation in more detail.

How do No Surprises Act protections apply to emergency services?

Under the No Surprises Act, a nonparticipating emergency facility and a nonparticipating provider cannot bill an emergency patient more than in-network cost sharing. 45 CFR 149.410(a) states this for both the facility and the provider, and it ties the cost-sharing requirement to the rules cited in that section.

The Act defines emergency services broadly. Under 45 CFR 149.110(c)(2)(i), they include the screening exam under section 1867 of the Social Security Act and the further exam and treatment needed to stabilize the patient, regardless of which hospital department provides them. The same definition covers emergency services in an independent freestanding emergency department.

Care after the patient is stabilized is treated separately. Post-stabilization services are not emergency services only if every condition in 45 CFR 149.410(b) is met, which includes a notice and consent process. Our No Surprises Act hub explains the full rules.

For a patient, this ends the balance bill. For you, it moves the argument to the payer. The patient owes the in-network amount, and the difference between that and a fair rate is fought out with the plan, not collected from the patient.

How do ER groups get paid when the payer underpays out-of-network?

An ER group recovers underpayments by negotiating directly with the payer and, if that fails, filing federal IDR. Under 45 CFR 149.510(b)(1)(i), either party starts a 30-business-day open negotiation period to determine the out-of-network rate. Under 149.510(b)(2)(i), either party then has a 4-business-day window, starting the first business day after open negotiation ends, to start IDR.

Those windows are short, and ED volume makes them easy to miss. A group with hundreds of emergency claims has to track a clock for each open negotiation notice. Our guide to the IDR process explains each step, and batching claims covers how to group claims into one dispute. The qualifying payment amount page explains how the payer's figure is built.

We work out-of-network emergency claims under federal IDR and applicable state pathways, including Texas TDI. The next section shows how a case runs, and the out-of-network billing and IDR service page covers the work from eligibility to outcome tracking.

How do we run out-of-network emergency claims for you?

We verify benefits every day for every patient you send. That sorts each visit to federal IDR (self-funded ERISA plans), a state process (fully insured plans regulated by a state) or neither: Medicare and Medicaid claims, including Medicare Advantage and Medicaid managed care, are outside the No Surprises Act dispute process.

You confirm the visit was in an emergency department or a freestanding emergency department, and we confirm the patient's plan and what it covers. We need the UB-04 and CMS-1500 claims, the medical records and the 835 ERA files or EOBs, plus payer contracts if you have them. We read the remark codes on each remittance to check NSA eligibility.

A designated NSA team owns each case. It starts from a dedicated email address, with printed documents and proof of submission in a separate folder per case. The team counts the 30-business-day open negotiation period and the 4-business-day window to start IDR from the day the remittance arrives. You pay the administrative fee and the IDR entity fee, and we tell you in writing when each is due.

Our team prepares the notices and dispute packages. An authorized user located in the US submits in the federal portal, as the portal's rules require, usually a person on your team set up during onboarding. After a decision we follow up with the payer, and we escalate when 45 days pass without payment.

Where we stand: 1,800 to 2,000 IDR cases finalized, and about 75% average win ratio. We show win rates by payer on a call, as totals only. We do not share references or sample dispute packages, because they contain other clients' and patients' information. Reports are monthly and customized, and NSA and IDR work is a monthly retainer based on your volume of eligible IDR patients, quoted on a call. Onboarding takes up to one week, and we agree the exact plan on the call.

How do freestanding ERs bill differently from hospital EDs?

A freestanding ER is billed differently mainly because of what it is licensed as. Under 45 CFR 149.30, an independent freestanding emergency department is a facility that is geographically separate, licensed separately from a hospital under state law, and provides emergency services. A hospital outpatient department that provides emergency services counts as an emergency department of a hospital instead.

The No Surprises Act protections extend to both kinds of facility, because emergency services under 45 CFR 149.110 include those in an independent freestanding emergency department. For claim forms, place of service codes and facility fee detail, read our freestanding ER billing guide rather than relying on this overview.

How we handle emergency department and freestanding ER billing

We bill the facility claim and the professional claim for the same emergency visit, so the two stay consistent. Our hospital and facility scope covers institutional (UB-04) claim preparation, revenue-code validation, submission, payment reconciliation and denial management for inpatient, outpatient and emergency care. Professional claims go out on the CMS-1500.

We send claims within 24 hours of charge entry and work denials within 48 hours. Before submission, our UB-04 accuracy checks look at bill type, revenue codes, patient status, condition and occurrence codes, authorization requirements and payer-specific rules. Our team has billed for US practices since 2018 and works to a 95% clean claim rate.

We align each EHR, clearinghouse and payer portal workflow with verified team experience, standard claim validation, reconciliation controls and performance monitoring. See denial management and medical billing for the other services in this work. When you are ready to talk, book a call.