Every patient seen, not every patient covered
Emergency physicians treat everyone who arrives, before anyone checks coverage. Groups therefore bill for patients whose insurance is unknown at the time of care, who are out of network, or who have no coverage at all. Registration data often comes from the hospital, so demographic and insurance errors are inherited. Coding has to be accurate at high volume, and collection depends on chasing information after the visit.
ED visit levels and critical care
| Service | Codes | Based on |
|---|---|---|
| Emergency department visits | 99281–99285 | Medical decision-making: problems addressed, data reviewed and risk — not time |
| Critical care | 99291, 99292 | Total documented time on the critical illness, excluding separately billed procedures |
| Observation and hospital services by ED physicians | 99221–99239 family | Setting and the physician’s role in the stay |
Documentation should make the decision-making visible: tests ordered and reviewed, independent interpretation of images or ECGs, discussions with consultants, and the risk of the management chosen, including decisions about admission.
Procedures in the ED
- Procedures such as laceration repair, fracture care, incision and drainage, intubation and central lines are billed in addition to the visit, with modifier 25 on the E/M when it is separately supported.
- Interpretations: an ED physician’s formal interpretation of an ECG or image may be billed only when it is the official report, not a review of someone else’s.
- Sedation by the same physician performing a procedure is reported with the moderate sedation codes when time and monitoring are documented.
Out-of-network emergency care and patient balances
Under the No Surprises Act, patients treated for emergencies by out-of-network clinicians pay only their in-network cost-sharing, and the group may not bill them for the balance. Payment disputes with the plan go through open negotiation and, if needed, the federal independent dispute resolution process, which has strict deadlines. EMTALA requires screening and stabilization regardless of ability to pay, so payment questions never delay care. Groups recover revenue through insurance discovery, accurate demographics from the hospital, and prompt patient statements — see reducing days in A/R.