CPT 99285
ER visit, level 5
The highest emergency room visit level, for high complexity decision making. It is meant for visits where something threatened life or a bodily function, or where the decisions carried high risk: emergency surgery, admission with a serious illness, a drug that needed intensive monitoring, or a decision to stop treatment.
Billed to Medicare
$1,232
What providers submitted, on average, for this code in a hospital setting.
Medicare accepted
$170
What Medicare treated as payable. Not a commercial rate or a cash price.
The gap
7.3x
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 9,076,785 services.
Among the 6 emergency room visit levels codes on this site with CMS figures, this gap ranks 2 of 6 (median 6.4x). The widest is ER visit, level 1 at 15.6x.
Where this line goes wrong
Level 5 for a visit that ended with 'go home and rest' is the classic error
The code needs high risk in the plan or a high severity problem. Being sent home the same day with no prescription, no admission and no procedure is hard to square with either. That combination is worth a written coding review every time.
It is worth checking on both bills
Hospitals and physician groups choose their levels separately. A level 5 facility charge next to a level 3 physician charge for the same visit means one of them is describing a different visit. Ask each for the criteria it used.
Critical care is a different code
If you were genuinely critically ill and a doctor spent 30 minutes or more on your care, that is billed as critical care (99291), not level 5. Seeing both on a physician bill for the same visit is a red flag: they are not normally billed together by the same doctor.
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 qualifies as a level 5 emergency room visit?
Since 2023, high complexity medical decision making: at least two of three elements at the high level, which are a severe or life-threatening problem, extensive data reviewed (for example tests plus an independent interpretation or a discussion with another physician), and high risk in the plan. Being seen quickly or waiting a long time does not count.
Can a hospital bill level 5 for a sprained ankle?
Only if its own written criteria for a level 5 facility visit were met, which for a simple sprain would be very unusual. Request the itemized bill and the visit record and ask for the hospital's ER level guidelines.
How do I dispute a 99285 charge?
In writing, to the billing office: state that you are requesting a coding review of the visit level, say what happened at the visit and what you were sent home with, and ask them to confirm which criteria supported a level 5. Keep a copy.
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.