Quick Answer: The Medicare-approved physician fee for a Level 4 ER visit (CPT 99284) is around $118, and for a Level 5 visit (CPT 99285) it is around $171. Your hospital's chargemaster list price for the same visits often runs $1,200 to $1,800 or more (just for the facility fee, before the doctor's separate bill arrives). That gap is where overcharges hide.
Most people open an ER bill and have no idea what they are looking at. A string of five-digit codes, a $4,000 total, and a "amount you owe" that may or may not reflect what your insurance actually negotiated. The confusion is not an accident. The billing system is genuinely complicated, and hospitals know that most patients will pay without asking questions.
This guide explains what CPT codes 99284 and 99285 actually mean, what the government says those visits should cost, and how to compare your bill against real benchmarks. If you have already received a bill that looks wrong, the CoveredUSA Bill Analyzer can flag line items that exceed Medicare rates in about 30 seconds.
The Five Levels of ER Visits (CPT 99281 Through 99285)
Every emergency department visit gets assigned a level (1 through 5) based on the complexity of your care. That level determines which CPT (Current Procedural Terminology) code appears on your bill and how much the hospital can charge.
| CPT Code | Level | Complexity | Typical Condition |
|---|
| 99281 | Level 1 | Minimal | Minor cut, splinter removal |
| 99282 | Level 2 | Straightforward | Earache, mild allergic reaction |
| 99283 | Level 3 | Low | Sprained ankle, simple UTI |
| 99284 | Level 4 | Moderate | Chest pain, moderate trauma |
| 99285 | Level 5 | High | Stroke, heart attack, severe trauma |
Levels 4 and 5 (CPT 99284 and 99285) cover the majority of actual ER bills because the bar for "moderate" complexity is lower than most patients expect. A fever with labs and IV fluids can land you at a Level 4. Severe abdominal pain with a CT scan often hits Level 5.
The level is supposed to be assigned based on medical decision-making, not on how long you waited or how crowded the ER was. Upcoding (billing a higher level than the care warranted) is one of the most common forms of hospital billing fraud.
What Medicare Actually Pays for 99284 and 99285
Medicare sets a physician fee schedule that represents the government's best estimate of fair payment for a given service. These numbers are published publicly each year. As of 2026:
| CPT Code | Medicare Physician Rate | Major Private Insurer Range |
|---|
| 99284 | $118.24 | $118 to $182 |
| 99285 | $171.35 | $169 to $267 |
Note that these are the physician fees only (what your emergency physician gets paid separately from the hospital). The hospital charges a facility fee on top of this.
Facility fees for the same codes run considerably higher:
| CPT Code | Median Facility List Price | Medicare Facility Payment | Cash Price (Median) |
|---|
| 99284 | $1,189 | approx. $230 to $350 | approx. $700 |
| 99285 | $1,784 | approx. $350 to $500 | approx. $1,097 |
The list price is what the hospital puts on the chargemaster (the internal price list hospitals are required to publish under 2021 federal transparency rules). Almost nobody actually pays that number. Insurance companies negotiate it down 30% to 79% depending on the payer type.
Why Your Bill Might Be Three to Ten Times the Medicare Rate
Here is the math on a typical Level 5 ER visit:
- Facility fee (chargemaster): $1,784
- ER physician fee: $173 to $267
- Lab work (two blood panels): $400 to $900
- CT scan (head or chest): $1,000 to $3,000
- IV fluids and medications: $200 to $800
Total chargemaster list price before any negotiation: $3,557 to $6,751.
If you have insurance, your insurer negotiates a contracted rate, usually 40% to 60% lower than list price. You then pay your deductible plus coinsurance (often 20%) on whatever the negotiated rate is.
If you are uninsured, hospitals are required to offer you a cash price that must be published and accessible. For CPT 99285, the median published cash price nationally is around $1,097 for the facility fee alone. But many hospitals still attempt to bill uninsured patients at chargemaster rates unless those patients explicitly ask for the cash price or apply for charity care.
The CoveredUSA Bill Analyzer compares each line item on your hospital bill against the Medicare rate for that specific CPT code, flagging anything that looks out of line with what the government considers reasonable payment for the same service.
The Two Bills Problem
One of the most confusing aspects of ER visits is receiving two completely separate bills:
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The hospital (facility) bill: covers the ER room, nursing staff, equipment, IV setup, and any procedures performed by hospital employees. This will show the facility-level CPT code (99284 or 99285).
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The physician bill: from the emergency physician group (often a separate company contracted to staff the ER). This bill covers the doctor's professional evaluation and will show the same CPT code but at the lower professional fee rate.
You can receive these bills weeks apart, from different addresses, with different insurance adjustments applied. Many patients pay both without realizing they should check whether the physician group was in-network separately from the hospital.
In 2022, the No Surprises Act banned surprise billing in most situations -- meaning if your hospital is in-network, the ER physician cannot bill you at out-of-network rates even if they are employed by a different group. If you received an out-of-network physician bill from an in-network ER visit after January 2022, you have the right to dispute it.
How to Spot an Overcharge on Your ER Bill
Step 1: Get an itemized bill. Call the hospital billing department and request one. A summary bill showing only totals is not sufficient to audit. You are legally entitled to an itemized version.
Step 2: Match each line item to a CPT code. Every charge should have a corresponding code. If you see vague descriptions like "medical supplies" without a code, ask for clarification.
Step 3: Look up the Medicare rate for each code. The CMS Physician Fee Schedule lookup tool at cms.gov is public and searchable. If a line item is billed at 10 times the Medicare rate, that is worth questioning.
Step 4: Check for duplicate charges. A common error is billing the same service twice -- once as part of the ER visit level and again as a standalone procedure.
Step 5: Verify your visit level. If you were assigned CPT 99285 (Level 5) but you were treated for something like a kidney stone or minor head injury, ask the hospital for documentation of what made it a high-complexity visit. Clinicians are required to have medical decision-making documentation to support the code.
Step 6: Ask about financial assistance before paying. If you are uninsured or underinsured, most nonprofit hospitals are legally required to have charity care programs. These programs can reduce or eliminate your bill based on income. You can also ask about a payment plan at 0% interest.
Income-Based Help for ER Bills
If you cannot afford your ER bill, several programs may help:
Medicaid: If your income is below roughly 138% of the Federal Poverty Level (FPL) in an expansion state, Medicaid may cover emergency services retroactively in some situations. Check your eligibility at CoveredUSA's screener.
Hospital charity care: Nonprofit hospitals with 501(c)(3) status must provide financial assistance. Many cover bills in full for patients under 200% FPL and offer sliding-scale reductions up to 400% FPL.
Medical debt negotiation: Hospitals almost always accept less than the listed balance on unpaid medical debt, especially for uninsured patients. Asking the billing department for a "prompt pay discount" or requesting to speak with a financial counselor is worth doing before any bill goes to collections.
The No Surprises Act protections: For out-of-network charges you believe were applied incorrectly, you can file a complaint through cms.gov or your state insurance commissioner.
What CPT 99284 vs 99285 Means for Your Out-of-Pocket Cost
The difference between a Level 4 and Level 5 designation on your bill is not just a coding technicality. It translates directly to money:
| Scenario | Typical Insured Out-of-Pocket | Typical Uninsured Cash Price |
|---|
| Level 4 (99284) with no imaging | $150 to $500 copay/coinsurance | $700 to $1,400 |
| Level 4 with labs + X-ray | $300 to $900 | $1,200 to $2,500 |
| Level 5 (99285) with CT scan | $500 to $1,500 | $2,000 to $5,000+ |
| Level 5 with admission | $1,500+ (inpatient deductible applies) | $5,000 to $20,000+ |
These ranges assume in-network care. Out-of-network costs can be dramatically higher, even after No Surprises Act protections are applied.
Frequently Asked Questions
What does CPT 99285 mean on my ER bill?
CPT 99285 is the billing code for a Level 5 emergency department visit -- the highest level, assigned when your condition required high-complexity medical decision-making. Common examples include stroke, heart attack, severe trauma, and respiratory failure. The physician fee Medicare pays for this code in 2026 is approximately $173. If your bill shows a facility fee of $1,500 to $3,000 for this code, that is within the range of typical (if inflated) chargemaster pricing. The negotiated rate your insurer actually pays is usually 40% to 60% lower.
What is the difference between CPT 99284 and 99285?
CPT 99284 covers moderate-complexity visits -- things like chest pain that turns out to be musculoskeletal, moderate trauma, or conditions requiring prescription management. CPT 99285 covers high-complexity visits where the risk of significant complications or mortality is higher. The difference matters because Level 5 bills average $500 to $600 more in facility fees than Level 4, and if your case was genuinely Level 4, being billed as Level 5 is upcoding.
Can I dispute my ER visit level?
Yes. You can ask the hospital to provide the documentation that supports the complexity level assigned. If the medical decision-making documented does not meet the criteria for the level billed, you can formally dispute it. Start with the hospital's patient advocate or billing department, then escalate to your insurance company's appeals process if needed.
What does the hospital facility fee cover?
The facility fee covers the ER room itself, nursing care, hospital-employed staff, equipment use, IV setup, and hospital-administered medications. It does not include the emergency physician's professional fee, which comes as a separate bill from the physician group. Both fees may show the same CPT code (99284 or 99285) but they are charged at different rates.
Am I required to pay chargemaster list prices?
No. Almost nobody pays chargemaster prices. If you have insurance, your insurer's contracted rate applies. If you are uninsured, you can request the hospital's cash price (which hospitals are federally required to publish) or apply for charity care. If you pay a chargemaster price without asking for alternatives, you likely paid more than necessary.
How do I know if I was overcharged?
Request an itemized bill, look up the CPT code for each line item, and compare the billed amount to the Medicare rate for your area. Any charge that is significantly above the Medicare rate -- especially for straightforward services like labs, IV placement, or basic imaging -- is worth questioning. Upload your bill to the CoveredUSA Bill Analyzer to get a line-by-line comparison against Medicare benchmarks automatically.
What is the average total cost of an ER visit in 2026?
The average total ER visit cost in the United States is approximately $2,715 as of 2025 to 2026, based on analysis of claims data. That average includes facility fees, physician fees, labs, and imaging for a typical moderate-to-high complexity visit. Uninsured patients without financial assistance face the highest exposure; patients with good employer coverage often pay $200 to $1,500 out of pocket depending on their deductible and copay structure.
Does Medicaid cover ER visits?
Yes. Medicaid covers emergency services in all states, and in Medicaid expansion states, anyone earning below approximately 138% FPL ($22,023 for a single person in 2026) qualifies. Even in non-expansion states, emergency Medicaid may cover the acute stabilization portion of an ER visit for people who would otherwise qualify. If you received an ER bill and are unsure whether you qualify for Medicaid, check your eligibility in 2 minutes at coveredusa.org.
Upload your hospital bill to the free CoveredUSA Bill Analyzer to find errors, overcharges, and charity care options in 30 seconds.
