Reviewed by Roey Hine
Key Takeaways
- An emergency medicine billing company works the professional claim from hospital-sourced data, since federal rules keep insurance questions from delaying emergency screening and stabilization.
- Its coders need to level ED visits on medical decision making alone, the CPT standard since 2023.
- Critical care has to be coded by payer, because Medicare and CPT set different time thresholds for add-on code 99292.
- Split/shared attestations between physicians and APPs need review, because the billing practitioner sets the Medicare payment rate.
- Useful reporting breaks out coding, denials, and charge lag by provider and payer.
An emergency medicine billing company has to code and collect on encounters the ED group never scheduled, using insurance data the hospital captured at registration. That changes what a billing partner has to be good at. This guide covers the scope, coding rules, reporting, and hiring questions that separate an experienced emergency medicine biller from a generalist.
What does an emergency medicine billing company do?
An emergency medicine billing company manages the professional revenue cycle for the physicians and advanced practice providers (APPs) in an ED group, from capturing charges out of hospital records through final payment. The hospital bills the facility component of the same visit on its own claim, using its own leveling criteria. Our post on physician billing and facility billing explains how the two claims relate.
For an ED group, the work includes:
- Pulling demographics, insurance, and clinical documentation from hospital registration and EHR systems
- Coding ED evaluation and management (E/M) visits, critical care, and bedside procedures for each clinician
- Checking modifiers and payer-specific edits through pre-submission claim scrubbing
- Following up on denials, underpayments, and appeals
- Billing patients for balances and resolving accounts with missing or incorrect insurance
- Reporting results by provider, payer, and site
Why is emergency medicine billing different from other specialties?
Emergency medicine billing starts after care is delivered, using information the group did not collect. The Emergency Medical Treatment and Labor Act (EMTALA) requires Medicare-participating hospitals that offer emergency services to provide a medical screening exam to anyone who requests one and stabilizing treatment for an emergency medical condition, regardless of ability to pay. Federal regulations bar hospitals from delaying that exam to ask about insurance, and from seeking payer authorization until the exam is complete and stabilizing treatment has begun.
As a result, eligibility checks, copays, and prior authorizations cannot gate an ED visit the way they gate a scheduled appointment. Registration can happen mid-treatment, and the insurance details it captures are sometimes incomplete. A patient brought in by ambulance, unresponsive and without identification, still generates a professional claim, and someone has to find the coverage after the fact. Patients who arrive uninsured or with outdated coverage produce claims that need insurance discovery, retroactive eligibility checks, or self-pay billing.
Each of those accounts needs a defined workflow, and every hospital the group staffs needs a reliable data feed. In our work with ED groups, that data feed is the first thing to get right, because every claim downstream depends on it.
How should ED E/M visits be coded?
ED E/M visits are coded on medical decision making (MDM) alone. Since January 2023, CPT has based levels 99282 through 99285 solely on MDM, with history and exam documented only as medically appropriate, and ACEP’s guidance confirms that time is not used to select ED E/M levels.
| ED E/M code | Required level of MDM |
| 99281 | None; the visit may not require a physician or other qualified health care professional |
| 99282 | Straightforward |
| 99283 | Low |
| 99284 | Moderate |
| 99285 | High |
MDM is scored on three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications from patient management. A visit supports a given level when two of the three elements meet or exceed it.
The 2023 revisions lowered the MDM requirement for 99282 and 99283 by one step each. Low MDM, the 99282 requirement before 2023, now supports 99283. Coders who still score history and exam elements, or who level ED visits on time, misstate a group’s acuity. Undercoding leaves earned revenue unbilled, and overcoding invites audits. When we review ED charts, the only leveling question is whether the documented MDM supports the code billed; a longer history and exam adds nothing to the level.
How should critical care be coded in the emergency department?
Critical care in the ED is reported only with time-based codes 99291 and 99292, and Medicare counts that time differently than CPT does. Under CPT, 99291 covers the first 30 to 74 minutes on a given date, and 99292 is added once total time passes 74 minutes. Since 2023, Medicare has required the full additional 30 minutes, or 104 total minutes, before the first 99292, according to ACEP’s critical care FAQ.
| Codes reported | CPT total time | Medicare total time |
| 99291 | 30-74 minutes | 30-103 minutes |
| 99291 + 99292 | 75-104 minutes | 104-133 minutes |
| 99291 + 99292 x2 | 105-134 minutes | 134-163 minutes |
A 90-minute critical care encounter, for example, bills as 99291 plus 99292 under CPT rules and as 99291 alone under Medicare.
Time spent on separately billable procedures, such as CPR (92950), endotracheal intubation (31500), or central line placement (36556), is excluded from the total. Services bundled into critical care, including pulse oximetry, chest x-ray interpretation, and ventilator management, are not billed on their own.
Medicare allows an ED E/M visit and critical care on the same date when the E/M visit came first and the patient later required critical care, with modifier 25 on the claim. If critical care began on arrival, the same physician reports one or the other. Billing software has to apply the right threshold to each payer automatically, and coders have to confirm that documented time excludes procedure time.
How should split/shared visits between physicians and APPs be billed?
A split/shared visit is billed under the practitioner who performed the substantive portion, and Medicare requires modifier FS on the claim. CMS permits split/shared billing only in facility settings, which include the ED. Since 2024, Medicare has defined the substantive portion as more than half of the combined total time or the substantive part of the medical decision making. Split/shared critical care is attributed by time alone.
Consider a visit where an APP takes the history, orders the workup, and the physician reviews results and decides on admission. The record has to show whose work made up the substantive portion, because that determines whose name goes on the claim.
Which practitioner bills determines the Medicare rate: the full fee schedule amount for the physician and 85% for the APP. The medical record must identify both practitioners and be signed by the one who bills. Commercial payers set their own split/shared policies, so a billing company needs payer-level rules on file.
What reporting should an ED group expect from its billing company?
An ED group needs reporting broken out by provider and payer, since group-level totals hide the patterns that matter most in emergency medicine. Useful reports include:
- E/M level distribution for each physician and APP, compared across the group
- Critical care frequency and reported time per provider
- Clean claim rate and denials by reason code, tracked against the most common denial types
- Charge lag, measured from date of service to claim submission
- Self-pay volume and insurance discovery results
- Collections by payer and facility for multi-site groups
A provider whose level 5 rate sits well below peers may be under-documenting MDM, and one well above peers may draw payer review. For ED groups, E/M distribution by provider is often the first report we look at, because outliers are easier to correct before a payer notices them.
What questions should an ED group ask before hiring an emergency medicine billing company?
These are the questions we would expect any ED group to ask us, and a billing company worth hiring answers each one with specifics:
- How do you receive registration and documentation data from each hospital we staff?
- How many days typically pass between a shift and claim submission?
- How do your coders score MDM for ED E/M visits, and how often do you audit levels by provider?
- How do you apply CPT and Medicare critical care time thresholds by payer?
- How do you review split/shared attestations and payer-specific APP rules?
- What is your process for patients with missing or incorrect insurance?
- Can we see sample provider-level and payer-level reports?
- Who is our day-to-day contact, and how quickly do they respond?
How PGM Supports Emergency Medicine Groups
PGM provides emergency medicine billing and revenue cycle management for ED physicians and APPs, including E/M and critical care coding, split/shared services, denial follow-up, and RCM reporting. Independently owned since 1981, PGM pairs every emergency medicine client with a dedicated account manager who knows the group’s coverage model, provider mix, and payer landscape. Contact PGM to discuss your group’s coding and collections.
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Frequently Asked Questions About Emergency Medicine Billing Companies
Should an ED group outsource billing or keep it in-house?
Outsourcing makes the most sense when a group lacks coders trained in ED MDM, payer-specific critical care rules, and split/shared attribution, or when charge lag and denials are climbing. Groups weighing the decision can start with what to look for in a medical billing company and compare that list against their current results.
How do emergency medicine billing companies charge?
Most billing companies charge a percentage of collections, which ties their revenue to what the group collects. When comparing proposals, confirm what the percentage applies to, which services are included, and whether patient statements, credentialing, or reporting cost extra. PGM’s fees are also collections-based.
What happens to outstanding claims when an ED group changes billing companies?
That depends on both vendor contracts. In a common arrangement, the outgoing company keeps working claims for dates of service before the cutover while the new company bills everything after it. Settle who owns that runout, for how long, and at what fee when negotiating the exit. Our post on why practices switch billing companies covers the most common reasons groups make a change.
Should a billing company handle provider enrollment for an ED group?
When an ED group adds a physician or APP, claims for that clinician can deny until enrollment with each payer is complete. A billing company that also provides credentialing services can time payer applications to each clinician’s start date. See what credentialing delays really cost your practice for how those delays add up.