Report points to payer leveling policies and documentation gaps as emergency groups lose revenue on correctly coded claims
ANAHEIM, Calif., October 14, 2026: Doctor Management Services (DoctorMGT), a medical billing, coding, credentialing, and revenue cycle management company, today released its Emergency Department Coding Report. The report examines how emergency department evaluation and management claims are being paid across the country.
Key Finding: Over Half of ED Claims Are Paid at a Lower Level
The report revealed that 52% of claims submitted within the CPT codes 99283, 99284, and 99285 were down-coded. This translates to a lower rate than the one that the payer paid them. The 99281-99285 series of visits each has a different payment, meaning that a Level 5 visit paid as a Level 4, or a Level 4 paid as a Level 3, does not have an explicit denial and so reduces the revenue. Many practices do not realize this, as the remittance just indicates a reduced allowance.
How the 2023 CPT Changes Raised the Stakes
From January 1, 2023, the number of emergency department visits is determined by medical decision making (MDM) rather than the outcome of the visit. There is no need to worry about time, and history and exam must be medically appropriate. The AMA also reduced the difficulty level for two levels: 99283 went from moderate MDM to low MDM, and 99282 went from low MDM to straightforward. The 4th and 5th levels remained moderate and high, respectively.
The level now depends on how a physician’s thinking is captured, and notes in the traditional history and exam format tend to lack details of why a visit should have been at that level.
Payer Policies Add Pressure
Some large payers use their own leveling criteria, and some will move Level 4 and Level 5 claims to other levels as follows: work performed is not the basis for Level 4 and 5 claims; the basis is the final diagnosis. On specific emergency department (ED) claims, UnitedHealthcare utilizes the Optum Emergency Department Claim Analyzer. On June 1, 2026, Florida Blue will implement a policy to help shift 99285 claims to 99284.
Getting the correct diagnosis can take an hour or more for an emergency doctor to rule out a life-threatening diagnosis. It is that effort that the higher levels will capture.
Recommendations for Emergency Practices
The report suggests practices check documentation for the three MDM elements: problems addressed, data reviewed, and risk. It further suggests that audits should be conducted on a quarterly basis on a sample of Level 4 and Level 5 claims; reassignment level down-coding rates should be monitored by the payer, and claims reassigned should be appealed with medical records and the payer’s own policy.
About DoctorMGT
DoctorMGT is a medical billing, coding, credentialing, and revenue cycle management company based in Anaheim, California. The company specializes in workers’ compensation, personal injury lien billing, and specialty practice management. To read the full report or speak with the team, visit www.doctormgt.com.
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