Coding, claims and collections for emergency physician groups, freestanding emergency centers and critical access hospital EDs, done inside the systems you already run.
Emergency revenue leaks at the chart: a high-MDM visit charged as 99284, critical care time that stops at 103 minutes, a laceration repair billed without modifier 25, or an out-of-network payment nobody disputes in time. A level 5 visit billed one level low loses $53.11 per Medicare claim at 2026 national rates. Luxen codes every ED chart to its documented decision making, tracks No Surprises Act deadlines and works denials so your group is paid for the care it delivered.
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Emergency room billing services code and collect for emergency department care: ED visit levels 99281 to 99285, critical care, bedside procedures, interpretations and out-of-network disputes under the No Surprises Act. In 2026 Medicare pays a national $171.35 for a level 5 ED visit (99285) before geographic adjustment.
We bill for the groups and facilities that staff emergency departments, and each bills differently.
Service lines we bill alongside the ED visit: critical care, bedside procedures, EKG and X-ray interpretations, observation care, trauma team activation (G0390 with revenue code 068x on the facility claim) and patient balances after insurance.
Emergency revenue is lost in the gap between what the chart documents and what the claim carries. Dollar figures are 2026 Medicare national facility rates at the $33.4009 conversion factor, before geographic adjustment.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Level 5 visit charged as level 4 | 99285, 99284 | High MDM documented, moderate level billed | $53.11 per Medicare claim | Charts re-leveled against documented MDM |
| Critical care of 75 to 103 minutes | 99291, 99292 | 99292 added before the Medicare 104-minute threshold | $100.20 per 99292 line | Time statements checked against 104 minutes |
| ED visit before the patient became critical | 99285, 99291, modifier 25 | ED visit dropped or billed without modifier 25 | $171.35 for the ED visit | Visit timestamps matched to critical care start |
| Laceration repair with a separate workup | 12002, 99283, modifier 25 | E/M bundled into the 0-day global procedure | $69.47 for the E/M | Procedure notes reviewed for separate MDM |
| EKG read in the ED | 93010 | Interpretation documented but never charged | $8.35 per read | Reads reconciled to the EKG log |
| Out-of-network emergency claim paid low | 99285, 99291 | Open negotiation notice not sent within 30 business days | The gap between the initial payment and a negotiated or IDR amount | Remittances calendared the day they post |
A handful of codes carry most emergency physician revenue, and each has a rule payers audit. Our certified medical coding team codes every chart to these rules before it goes out. Rates are 2026 Medicare national facility amounts at the $33.4009 conversion factor.
Since January 1, 2023, CPT levels 99282 to 99285 by medical decision making (MDM), with a medically appropriate history and exam. Time is not a descriptive component for ED visits, so a long stay does not raise the level on its own.
| Code | Level requirement | 2026 national rate |
|---|---|---|
| 99281 | May not require a physician or other QHP | $11.02 |
| 99282 | Straightforward MDM | $40.42 |
| 99283 | Low MDM | $69.47 |
| 99284 | Moderate MDM | $118.24 |
| 99285 | High MDM | $171.35 |
| 99291 | Critical care, first 30 to 74 minutes | $199.07 |
| 99292 | Each additional 30 minutes | $100.20 |
Documented MDM supported a higher ED visit level than billed on 9% of claims, across 8,400 emergency physician claims (Luxen claim audit).
CPT adds 99292 once critical care passes 74 minutes. Medicare pays 99292 only after a whole additional 30 minutes, at 104 total minutes. Under 30 minutes, 99291 is not billed. An ED visit and critical care on the same date can both be paid when the record shows the ED visit came before the patient needed critical care, with modifier 25 on the claim.
A simple laceration repair (12002, $57.45) and endotracheal intubation (31500, $132.94) carry 0-day global periods. A same-day ED visit is paid only when it is significant and separately identifiable, reported with modifier 25. Time spent on separately billed procedures, such as intubation, does not count toward critical care minutes.
When a physician and an NP or PA in the same group both see a patient, the practitioner who performs the substantive portion bills the visit with modifier FS. Since 2024, the substantive portion is more than half of the total time, or a substantive part of the MDM. The emergency department is an eligible setting; office visits are not. Critical care can also be split or shared: FS goes on the critical care codes, and 99292 is added once cumulative time reaches 104 minutes.
Modifier FS was missing on 11% of split or shared ED visits (Luxen claim audit).
Medicare contractors generally pay for only one interpretation of an EKG or X-ray furnished to an emergency room patient, the one that contributed to diagnosis and treatment. ED physicians bill the professional read only: 93010 for the EKG ($8.35) and 71045-26 for a single-view chest X-ray ($8.35). The value is volume: at the Medicare national rate, a group reading 1,000 EKGs a month leaves $8,350 unbilled if reads never reach the claim.
Under Method II, a critical access hospital bills reassigned emergency physician services on the institutional claim. Medicare pays them at 115% of the fee schedule amount, and facility services at 101% of reasonable cost. A 99285 at the 2026 national rate becomes $197.05 under Method II.
The No Surprises Act sets deadlines that decide whether an underpaid out-of-network emergency claim is ever recovered. Our denial and AR recovery team calendars each one from the remittance date.
Out-of-network emergency providers may not bill the patient beyond in-network cost sharing, and notice and consent cannot be used for emergency services or for emergency medicine as an ancillary service.
| Step | Deadline or amount | Rule |
|---|---|---|
| Send the open negotiation notice | Within 30 business days of the initial payment or denial | 45 CFR 149.510(b)(1) |
| Open negotiation | 30 business days from the notice | 45 CFR 149.510(b)(1) |
| Start federal IDR | Within 4 business days after negotiation ends | 45 CFR 149.510(b)(2) |
| Administrative fee | $15 per party per dispute from June 11, 2026 ($115 before) | 45 CFR 149.510(d)(2) |
| Certified IDR entity fee | Set by each certified IDR entity and published by CMS | CMS certified IDR entity list |
A batched dispute must share the provider, the plan or issuer and the service code, with services furnished within 30 business days. New batching rules, including batched line-item limits, apply to disputes whose open negotiation begins on or after November 1, 2026.
State-regulated plans can follow a state process instead. Texas sends provider disputes to arbitration requested 20 to 90 days after the first claim payment and does not apply to self-funded employer plans or Medicare (see Texas medical billing rules). Michigan's surprise billing law does not reach self-funded plans offered by private employers, so those claims go federal (see Michigan medical billing).
For Medicare, 99292 is reported only after a whole additional 30 minutes, at 104 total minutes (CMS critical care FAQ). Each early 99292 is a $100.20 line exposed to denial or recoupment. 99292 was billed before 104 minutes of documented critical care time on 7% of Medicare critical care claims (Luxen claim audit).
Medicare Advantage plans must pay emergency services under the prudent layperson definition regardless of final diagnosis (42 CFR 422.113), and Medicaid managed care plans may not limit emergency conditions by lists of diagnoses or symptoms (42 CFR 438.114). Each unappealed denial is a full visit lost. Appeals filed by Luxen were overturned 68% of the time (Luxen client data).
EMTALA bars delaying the screening exam or treatment to ask about payment or insurance; registration may ask only when it causes no delay (42 CFR 489.24). Coverage is found after the visit instead, and Medicaid can be effective as early as the third month before application (42 CFR 435.915), a window that narrows to one month for expansion adults applying from January 1, 2027. A visit left in self-pay bills the wrong party. Our eligibility verification and patient billing teams work these visits before statements go out. Eligibility and coverage errors caused 24% of denials (Luxen claim audit).
The open negotiation notice must go out within 30 business days of the initial payment or denial, and IDR must start within 4 business days after negotiation ends (45 CFR 149.510). A missed window closes federal IDR for that claim. Across 7 emergency groups, 38% of eligible out-of-network claims passed the open negotiation deadline unworked (Luxen billing reviews).
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
We work inside the systems your emergency department already runs. No migration and no new screens for physicians.
We sign the BAA before access and bill from the ADT and charge feeds, signed charts and remittances your group already receives.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Luxen client data, 38 client practices, Jan 2024 to Jun 2026:
For emergency transport billing, see how King-American Ambulance cut days in AR from 71 to 38.
Incomplete insurance and demographic information was leaving hundreds of emergency visits unbilled. Luxen introduced a post-visit coverage workflow, reduced unbilled encounters by 81%, and recovered $86,400 in the first quarter.
Billing Director, emergency physician group
Critical care time and bedside procedures were documented, but they did not always reach the final claim. Luxen reviewed 4,200 encounters, identified 129 missed services, and captured $57,400 in additional charges.
Medical Director, independent emergency medicine group
Full engagements are written up in our dental practice case study and our ambulance billing case study.
Emergency groups treat every patient before coverage is confirmed, so AR ages in self-pay and out-of-network buckets that office practices rarely carry. Benchmarks come from Luxen billing reviews (410 practice billing reviews, Jan 2025 to Jun 2026) and the Luxen claim audit (61,400 claims audited, Jan 2025 to Jun 2026).
| KPI | Why it matters in emergency billing | Luxen benchmark |
|---|---|---|
| Days in AR | High visit volume, low balance per claim | Emergency physician groups carried a median 51 days in AR |
| Unworked denials | Small ED claims are easy to write off one at a time | 19% of denied claims were never reworked or appealed |
| Timely filing | Unsigned charts push charges toward payer limits; Medicare allows 1 calendar year from the date of service | Timely filing caused 6% of denials, and only 4% of those were recovered |
| Eligibility | Coverage is confirmed after the screening exam, not before | Eligibility and coverage errors caused 24% of denials |
| Underpayments | Commercial ED levels paid below contract | Underpayments against contracted rates appeared on 7.8% of paid claims; the average underpaid claim was short by $38 |
Practices that reviewed AR ageing monthly carried 12 fewer days in AR. We report these by payer class, ED level mix and hospital site every month.
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, depending on visit volume, payer mix and out-of-network dispute workload. No setup or exit fee.
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| ED visits (99281 to 99285) | $112,000 | $3,360 | $6,720 |
| Critical care (99291, 99292) | $28,800 | $864 | $1,728 |
| Procedures and interpretations | $19,200 | $576 | $1,152 |
| Total | $160,000 | $4,800 | $9,600 |
| Cost | In-house | Luxen |
|---|---|---|
| Monthly | $12,640 (7.9% of collections) | $4,800 to $9,600 |
| Annual | $151,680 | $57,600 to $115,200 |
| When a biller leaves | Open biller roles took a median 67 days to fill | No gap in coverage |
| Terms | Salaries, benefits and software | Month to month, 30 days notice |
Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data (Luxen billing reviews). This group collects $1.92M a year.
| Partner type | ED coding depth | No Surprises Act work | Reporting | Terms |
|---|---|---|---|---|
| In-house biller | Depends on one person | Rarely tracked | Built by your staff | Payroll and turnover |
| Generalist billing company | Office E/M focused | Often not included | Standard aging reports | Often annual terms |
| Specialty emergency billing company | ED levels and critical care | Sometimes a separate fee | Varies | Varies, some charge setup fees |
| Hospital or EHR vendor RCM | Built around facility workflows | Limited for the physician group | Inside the vendor platform | Tied to the hospital contract |
| Luxen | Certified coders for ED levels, critical care and procedures | Included in denial and AR work | Monthly denials, AR and level mix | Month to month, 30 days notice |
Compare medical billing companies on these points, or see what full-service medical billing covers.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
Usually, yes. The hospital sends a facility claim on the UB-04 with revenue code 0450 and a level set by its own resource-based guidelines, while the emergency physician group sends a professional claim with place of service 23 and a level based on medical decision making. The two levels can differ for the same visit.
Luxen charges 3% to 6% of collections, depending on visit volume, payer mix and dispute workload. For a group collecting $160,000 a month, that is $4,800 to $9,600. Fully loaded in-house billing cost 7.9% of collections for practices under $2M in Luxen billing reviews.
About 2 weeks from signed BAA to working claims; median time from signed BAA to first claims worked was 9 business days across Luxen clients. We start with out-of-network disputes still inside their deadlines and the oldest recoverable claims, so first recovered payments arrive in about 3 weeks. There is no migration, setup fee or exit fee.
Yes. We work inside the hospital EHR and your group's practice management system, including Epic, Oracle Health, MEDITECH Expanse, T-System and athenaOne. We sign a BAA before access and work from the ADT and charge feeds your hospital already sends.
Yes. Under 45 CFR 149.30, participating and nonparticipating emergency facilities include an independent freestanding emergency department licensed separately from a hospital under state law, so emergency services there get in-network cost sharing and no balance billing. Texas licenses these centers under Health and Safety Code Chapter 254.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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