You may have just received a bill from the emergency room and noticed a vague ER level charge. These charges tend to be of high cost, and do not provide any apparent explanation as to the care you received. So what are these charges, and how are they determined?
What is an ER Level Charge?

ER level charges are broad, vague, and relatively unregulated charges that hospitals can impose by implementing algorithms based on the services you received. The concept behind the fee is to recover the cost of the staff time, staff knowledge and training, and physician involvement in your visit. These charges are also known as Evaluation and Management (E/M) Service Guidelines. Below I hope to clarify what each different level means and what is required to apply the charge. Included will be the codes that hospitals use to reflect the cost (don’t worry too much about the codes, that is why hospitals hire coders)

CPT 99281

This charge is the lowest level charge that can be applied in the ER setting. It requires little intervention from a provider and is usually resolved quickly. This is also known as a Level 1 ER Charge. These are typically applied to patients who have minor ailments or injuries. The requirements for this charge are

  • A problem focused history
  • A problem focused examination
  • Straightforward medical decision making

CPT 99282

Also known as a Level 2 ER visit, these visits require more intervention from the medical staff and are applied to patients with low to moderate injury/illness. There will be increased coordination between clinical staff and ancillary staff to ensure the care provided is adequate and thorough. The requirements for a hospital to apply this charge are

  • An expanded problem focused history
  • An expanded problem focused examination
  • Medical decision making of low complexity

CPT 99283

The Level 3 ER visit, is one of the more common charges I have seen on non-trauma patients. Patients presenting with moderate injuries or ailments (e.g., broken forearm) and require one x-ray and maybe some other small testing. Once again three required components must be met for this charge to be applied:

  • An expanded problem focused history
  • an expanded problem focused examination
  • medical decision-making of moderate complexity

CPT 99284

E/M level four also known as a level four ER visit, usually present as patients with illness or injury of high severity and require urgent evaluation by the physician or other qualified healthcare professionals but do not pose an immediate significant threat to life or physiological function. The three required components of this charge are:

  • a detailed history
  • a detailed examination
  • medical decision-making of moderate complexity

CPT 99285

Level 5 ER charges usually present as patients with high severity of illness or injury and post an immediate significant threat to life or physiologic function. There is a considerable amount of counseling and coordination of care with other physicians and other qualified healthcare professionals or agencies to provide appropriate and adequate care for the patient. The three requirements for this charge are as follows:

  • a comprehensive history
  • comprehensive examination
  • medical decision-making of high complexity

Critical Care

Critical care is defined as “direct delivery by a physician or other qualified healthcare professional of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”. Some examples of what might qualify as critical care are vital organ system failure such as central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, or respiratory failure.

  • CPT 99291 – this code is used to report the first 30 to 74 minutes of critical care on one specific given date can only be given once per calendar day and must meet a minimum of 30 minutes.
  • CPT 99292 – this code is used to report additional blocks of time of up to 30 minutes each beyond the first 74 minutes.

Hopefully, this short guide provided some insight as to what you see on your bill. As you notice, the guidelines are vague, and regulations have left it to the hospitals to decide what falls under what category. The only requirement the hospitals must follow is that they apply it consistently to all patients. This is usually done by pre-established algorithms based on services used illness injury resources used in intervention required. Due to the vagueness of these charges, they are frequently appealable if the proper arguments are made. One might be able to lower a level charge through appropriate medical record review and an adequately worded appeal letter. These are all very confusing which is why people make careers out of understanding this. If you have any further questions or want clarification, I invite you to reach out via info@bluberrypi.com.

Your Advocate,

Erik Wikman