CPT 99284
ER visit, level 4
An emergency room visit with moderate complexity decision making. Usually more than one problem, or one problem that needed several tests and a real decision about the risk: chest pain worked up and sent home, abdominal pain with a CT scan, a fracture that needed setting.
Billed to Medicare
$788
What providers submitted, on average, for this code in a hospital setting.
Medicare accepted
$115
What Medicare treated as payable. Not a commercial rate or a cash price.
The gap
6.9x
How many times the accepted amount the billed figure was.
National averages from the Centers for Medicare & Medicaid Services, 2024 data, retrieved 2026-09-14. Medicare fee-for-service, physician and practitioner claims only. The hospital's own charge for the same code is separate and is usually higher. Based on 4,531,103 services.
Among the 6 emergency room visit levels codes on this site with CMS figures, this gap ranks 3 of 6 (median 6.4x). The widest is ER visit, level 1 at 15.6x.
Where this line goes wrong
The fastest growing ER code
In national all-payer claims the share of ER visits coded at level 4 rose from about a third in 2018 to about 40% in 2023. Some of that is sicker patients. Some of it is coding. A level 4 for a visit with one simple problem and one test is the pattern to question.
Check what the 'moderate risk' was
Level 4 needs moderate risk in the plan, which in practice means things like prescription drug management, a decision about surgery, or a decision to admit versus send home. If the plan was rest, fluids and over-the-counter medicine, ask how moderate risk was reached.
Check it, then ask
- 1
Request the itemized bill and the visit record (the ER note). The level has to be justified by what is written there, not by what happened to you.
- 2
Check which bills carry the code. The hospital and the ER doctor usually each bill a level, and they do not have to match.
- 3
Compare the level to what was done: how many problems were addressed, what tests were ordered and reviewed, and what the decisions were (admit, discharge, prescription, procedure).
- 4
If the visit looks like a lower level, write to the billing office asking for a coding review and say which level you think fits and why. Ask for the response in writing.
The full walkthrough for this kind of bill: You got an ER bill.
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People also ask
What is the difference between a level 4 and level 5 ER visit?
Level 5 requires high complexity: a problem that threatened life or bodily function, or decisions like emergency surgery, hospital admission with a serious condition, or drugs that need intensive monitoring. Level 4 is moderate on the same scale.
The doctor billed a level 4 but the hospital billed a level 5. Is that allowed?
Yes, they use separate criteria. But it is a fair question to put to both. Ask the hospital for its written ER level guidelines, which it is required to have, and ask which points on that scale your visit met.
Sources
- ACEP, 2023 AMA CPT documentation guideline changes for ED E/M codes 99281-99285
- Trilliant Health, Changes in coding intensity suggest how upcoding is happening across outpatient settings (May 2025)
This page explains a billing code in general terms. It is not a coding, legal or medical opinion about your bill, and the code descriptions are mediloop's own plain-English summaries, not the official CPT descriptors, which are owned by the American Medical Association. Whether a charge was correct depends on the record of your visit and your payer's rules.