The 99284 CPT code is one of the most billed codes in the emergency department. However, it is also a frequent audit target. In this guide, you will learn what 99284 means, how to document it, and how payers reimburse it in 2026.
What Is CPT Code 99284?
Definition and Criteria
The 99284 CPT code reports an ED visit that needs a medically appropriate history and exam, plus a moderate level of medical decision making (MDM). Since 2023, ED codes use MDM only. In other words, time does not count toward the level.
To reach moderate MDM, the visit must meet two of these three elements:
| MDM Element | Moderate Level Example |
| Problems | An acute illness with systemic symptoms, or a chronic illness that is getting worse |
| Data | Ordering or reviewing three tests, or reading an EKG or X-ray yourself |
| Risk | Prescription drug management, for example |
Clinical Examples
- Abdominal pain that needs labs and a CT scan.
- Chest pain with a normal EKG and troponin, treated with a new prescription.
- Asthma flare that needs breathing treatments and oral steroids.
- Kidney stone pain managed with IV fluids and pain medicine.
Documentation Requirements for 99284 CPT Code
Required Chart Elements
- First, the chief complaint and a relevant history.
- Next, a medically appropriate exam.
- Then, the tests ordered and the provider’s review of results.
- Also, the differential diagnosis and the final impression.
- Finally, the treatment plan and disposition.
Risk Points Auditors Look For
Auditors focus on MDM. For instance, they check whether the notes show real decision making, not just a list of tests. In addition, they look for clear risk, such as new prescriptions. Without this proof, payers may downcode the visit to 99283. As a result, you could face payer denials or lower payment.
99284 Emergency Room Coding Guidelines by Payer
Medicare Requirements
Medicare follows the CPT MDM rules for the professional claim. Also, if the provider does a separate procedure, such as a laceration repair, add modifier 25 to the E/M line. In addition, Medicare publishes an E/M services guide through its MLN program.
Private Payer Variations
Most commercial payers follow CPT as well. Still, some use their own tools to review high-level ED claims. For example, a payer may compare the diagnosis with the billed level. So, always review each payer’s ED policy.
Facility vs Professional Billing
Hospitals also bill ED levels on the facility claim. However, facility levels follow each hospital’s own internal criteria, not MDM. Likewise, ER supplies charges go on the facility side.
99284 Reimbursement Rates 2026 and Fee Schedule
2026 Medicare National Rate
Medicare pays 99284 under the Physician Fee Schedule. Rates vary by location and change each year. Therefore, check the current amount in the CMS fee schedule lookup.
Documentation Tip:
Write a short MDM summary at the end of each note. For example, state the problem, the data you reviewed, and the risk of treatment. In turn, this makes the level easy to defend.
Commercial Payer Averages
Commercial rates often run higher than Medicare. However, they depend on your contracts and region. So, compare actual payments to your contracted rates to catch underpayments.
Conclusion
To sum up, the 99284 CPT code covers ED visits with moderate MDM. Document the problem, the data, and the risk clearly. Then, add modifier 25 when a separate procedure applies. As a result, your emergency care services will get paid at the right level.
FAQs
What is the 99284 CPT code?
It is the code for an emergency department visit with moderate medical decision making.
Does time count for 99284?
No. Instead, ED codes use MDM only.
What is the difference between 99284 and 99285?
99284 requires moderate MDM. In contrast, 99285 requires high MDM.
When do I add modifier 25 to 99284?
Add it when the provider also performs a separate procedure on the same day.
