Emergency room visit levels 1 to 5: what each level bills
An ER visit is billed at one of five levels, CPT 99281 to 99285, and usually twice: once by the hospital and once by the emergency physician. For CY2026, Medicare's hospital anchor runs from $86.15 at level 1 to $608.43 at level 5, and the physician anchor from $11.65 to $181.58. The level code on each bill is the line to check first.
If your bill says "level 5" or shows CPT 99285, you are looking at the top of a five-step scale that every emergency department in the country uses. Below are the Medicare anchors for each step on both sides of the bill, what the codes mean in billing terms, and the questions that get you the reason a level was chosen. It covers money only. Whether to go to an emergency department is a medical decision, and if you believe you have an emergency, call your local emergency number or go to the nearest emergency department without stopping to research prices.
The five levels, with both Medicare anchors
The table renders from this site's checked-in data file for CY2026. Hospital amounts are the national unadjusted outpatient payment rates and minimum unadjusted beneficiary copayments for Type A emergency departments, before the hospital's wage-index adjustment. Physician amounts are fee schedule participating amounts for Michigan Locality 01; your locality will differ.
| Level | CPT | CMS file description, in plain terms | Hospital facility anchor (APC) | Minimum Medicare hospital copay | Physician fee anchor |
|---|---|---|---|---|---|
| 1 | 99281 | may not require a physician or other qualified professional | $86.15 (APC 5021) | $17.23 | $11.65 |
| 2 | 99282 | straightforward medical decision making | $156.87 (APC 5022) | $31.38 | $42.74 |
| 3 | 99283 | low medical decision making | $278.89 (APC 5023) | $55.78 | $73.73 |
| 4 | 99284 | moderate medical decision making | $426.30 (APC 5024) | $85.26 | $125.73 |
| 5 | 99285 | high medical decision making | $608.43 (APC 5025) | $121.69 | $181.58 |
Sources: CMS OPPS CY2026, October 2026 Addendum B (updated October 15, 2026); CMS PFS CY2026 RVU file (Oct 2026) and GPCI, Michigan Locality 01. Verified 2026-10-22. Medicare anchors, not patient prices. The facility and physician columns are separate bills and are not added into a total here, because no source publishes one.
Reading the table: three things it shows
The hospital side is the larger layer at every level
At every level, the facility anchor is several times the physician anchor. At level 3, for example, the hospital anchor is $278.89 against $73.73 for the physician. That is the same pattern as other hospital outpatient services on this site: the hospital's payment covers the department, staff, equipment and supplies, while the physician fee covers the professional work. Our guide to hospital outpatient billing versus imaging centers explains that two-layer structure for scans.
The steps get larger at the top
Moving from level 4 to level 5 adds $182.13 to the hospital anchor and $55.85 to the physician anchor. Because the hospital and the physician each submit their own claim with their own code, the two bills for one visit can show different levels. If yours do, ask each billing office how its level was assigned.
Level 1 is unusual
The CMS file describes 99281 as a visit that may not require a physician or other qualified professional. Its anchors are the smallest on both sides, $86.15 for the hospital and $11.65 for a physician.
Two bills, two levels, two sets of rules
The hospital and the emergency physician each assign a level, and each bill follows its own payment system.
| Hospital facility claim | Emergency physician claim | |
|---|---|---|
| Who sends it | The hospital | The emergency physician group, often a separate company |
| Medicare payment system | Outpatient Prospective Payment System: level-specific APC 5021 to 5025 | Physician Fee Schedule, facility rate for 99281 to 99285 |
| Status in the CMS addendum | Status indicator J2 for 99281 to 99285, the same status indicator Addendum A gives the comprehensive observation APC 8011 | Not applicable |
| Other lines on the same claim | Imaging, labs, drugs, supplies, possibly observation | Sometimes separate procedure codes for work the physician performed |
| Who to ask about the level | The hospital's patient financial services office | The physician group's billing office, named on its bill |
Other physicians may bill too: a radiologist for reading a scan, a pathologist for a lab test, a consultant who saw you. Those bills are separate from the visit level. For a scan done during the visit, our procedure pages give the Medicare anchor for the scan itself, such as head CT without contrast.
What changes the level, in billing terms
For the physician claim, the CMS 2026 fee schedule file describes 99282 to 99285 by the level of medical decision making: straightforward, low, moderate and high. Medical decision making is the coding concept for how complex the evaluation was, and it is documented in the physician's record of the visit. How a clinical situation maps to a level is not covered here; that is a coding question answered by the record.
For the hospital claim, this guide does not describe how levels are assigned. The hospital's billing office can tell you how it assigned the level it billed and which documentation it relied on, and that is the question to ask.
Some emergency visits are not billed with a level at all. When critical care is provided, the claim may instead show CPT 99291, described in the CMS file as critical care for the first hour, which the outpatient addendum assigns to its own payment group, APC 5041, at $843.92 national unadjusted for the hospital. If you see 99291 rather than a 9928x code, the five-level table above is not the right comparison; the line in the neighbors table further down is. As with any code, the itemized bill and the record of the visit are where the reason for it is documented, and the billing office is the place to ask.
If you want to understand a level, the documents that answer the question are the itemized bill, which shows the code, and the medical record, which shows the documentation behind it.
Questions to ask about a level 4 or level 5 bill
- Ask the hospital for an itemized bill showing the CPT code for the visit level and every other line. Our guide to checking an itemized bill for errors explains how to go through it.
- Ask the physician group for its itemized claim. Note the level it billed and compare it with the hospital's.
- Ask each billing office, in writing, what documentation supported the level it billed.
- If you have insurance, compare each bill with the explanation of benefits for that claim before paying; our guide to reading an explanation of benefits shows how.
- If you believe a level does not match the documentation, ask for a coding review. Keep your request and the response.
- Only once the bills are correct, discuss the amount, a payment plan or financial assistance, in the order set out in our guide to negotiating a hospital bill.
What a person with Medicare pays
For Original Medicare, an emergency department visit is a Part B outpatient service unless you are formally admitted. Part B coinsurance applies to both bills after the 2026 Part B deductible of $283, according to CMS. The hospital copayment is based on the hospital's outpatient payment, and the table above shows its minimum unadjusted amount for each level, from $17.23 at level 1 to $121.69 at level 5, before local adjustment. The physician coinsurance is generally 20% of the fee schedule amount. Medicare.gov adds that the copayment for a single outpatient hospital service cannot be more than the inpatient hospital deductible, $1,736 in 2026.
If you stayed after the visit under observation, or were admitted, the bill changes shape. Our guide to observation status versus inpatient status explains how, including why the time you spend in the emergency department does not count toward Medicare's 3-day inpatient rule for skilled nursing care.
One level 4 visit, worked through for a Medicare patient
The example below uses only the anchors in the table and the 2026 Part B figures. It is hypothetical: a person with Original Medicare and no supplemental coverage, who has not yet met the Part B deductible this year, is seen in a Type A emergency department, billed at level 4 by both the hospital and the physician, and sent home. Real amounts differ because the hospital rate is adjusted for local wages, the physician rate depends on the locality, and other services on the claim add their own lines.
| Step | Hospital claim (APC 5024) | Physician claim (CPT 99284) |
|---|---|---|
| Medicare anchor | $426.30 | $125.73 |
| Minimum unadjusted hospital copayment, or 20% physician coinsurance | $85.26 | $25.15 |
| Part B deductible ($283 in 2026) | Applied to the first Part B amounts processed, so in a year with no earlier Part B claims, much of this visit can fall to the deductible before coinsurance applies | |
The table does not total the two columns. They are separate bills from separate organizations, processed as separate claims, and the order in which the claims are processed decides which one absorbs the deductible. What the example does show is the shape of a Medicare emergency bill: two claims, each with its own share, and a deductible that sits in front of both early in the year. When the claims are processed, Medicare's statement shows how each one was handled, and that is the document to compare with each bill.
Using the anchors if you have no insurance
For a self-pay patient, the anchors are not a price anyone has promised. They are useful in three narrower ways.
- Order of magnitude. If the hospital's charge for a level 3 visit is many times the $278.89 Medicare anchor, that tells you something about the hospital's list prices, and it is a reasonable point to raise when you ask about a self-pay discount.
- Matching the level. The level code on the bill tells you which row of the table to compare against. A bill that shows a different level from the physician bill for the same visit is worth asking about before paying either.
- Separating the layers. The table makes clear that the hospital and the physician are two layers. A discount or assistance approval from the hospital does not automatically apply to the physician group's bill, so ask each one.
Hospitals also publish their own prices for many services under federal price transparency rules, and our guide to using a hospital's published prices explains how to look up the posted cash price for a service code. That figure, not the Medicare anchor, is the hospital's own stated number to start from.
When a level looks wrong: making the request specific
A general complaint that a bill is too high is easy to set aside. A specific request is not. If you think a level does not fit what happened, put it in writing to the billing office that assigned it, and include four things: the date of service and account number; the code billed, for example 99285; the services you recall receiving, such as tests, imaging or medicines; and a request that the office review the level against the documentation and tell you in writing whether it stands. Ask for your medical record from the visit at the same time, so you can read the documentation yourself.
Keep the request factual. Billing offices review coding, not clinical judgment, and a request framed as a coding question is the one they can answer. If the level is corrected, ask for a corrected bill and, if you are insured, confirm that the corrected claim was sent to your plan so the explanation of benefits matches.
For insured and uninsured patients
With commercial insurance, your share of each bill is set by your plan's deductible, coinsurance or ER copay applied to the plan's allowed amount for that level, which is usually different from the Medicare anchor. Federal emergency protections under the No Surprises Act limit out-of-network billing for emergency care; how they apply to an ER visit, and where they stop, is explained in our urgent care versus emergency room guide. CMS lists the No Surprises Help Desk at 1-800-985-3059 for questions about those protections.
Without insurance, the Medicare anchors are a reference point, not a price. A hospital's charge for the same level can be far higher. Nonprofit hospitals must have a written financial assistance policy, and our guide to hospital financial assistance explains how it can reduce an emergency bill. If an ambulance brought you, that bill is separate again, and ground ambulance service is outside the No Surprises Act, as our ground ambulance guide explains.
Other emergency department lines you may see
The CMS outpatient addenda list several neighbors of the five Type A levels. They appear on bills less often, and each has its own Medicare anchor.
| Line on a hospital claim | CMS payment group, CY2026 | National unadjusted hospital payment |
|---|---|---|
| Type B emergency department visit, level 1 (G0380) | APC 5031 | $75.94 |
| Type B emergency department visit, level 5 (G0384) | APC 5035 | $419.62 |
| Critical care, first hour (CPT 99291) | APC 5041 | $843.92 |
| Hospital outpatient clinic visit (G0463), for comparison | APC 5012 | $136.02 |
Source: CMS OPPS CY2026 October 2026 Addendum A and Addendum B, checked October 22, 2026. National unadjusted, before wage-index adjustment.
Type B emergency departments are a separate category in the CMS addenda, paid at lower Medicare rates than Type A departments for the same level. If you visit a freestanding or off-campus emergency facility, ask how it bills and whether it is part of a hospital. The clinic visit line is included only to show scale: a hospital-based clinic visit has a Medicare anchor well below most emergency levels.
A record to keep from any emergency visit
- The date and time you arrived and left.
- The names of the hospital and any physician groups whose bills arrive.
- The visit level code on each bill.
- Tests and treatments you remember receiving, to match against the itemized bill.
- Whether you were admitted, kept under observation, or sent home.
That short list turns a confusing stack of bills into claims you can check one at a time. The procedure and billing-layer pages on this site give Medicare anchors for many of the tests that appear beside a visit level.
About the five levels
What are the five ER visit levels?
Emergency department visits are billed under CPT codes 99281 to 99285, level 1 to level 5. In the CMS 2026 fee schedule file, levels 2 to 5 are described by the level of medical decision making, from straightforward to high, and level 1 is a visit that may not require a physician or other qualified professional.
Why do I get two charges for one ER visit level?
Because two parties bill. The hospital bills a facility charge for the emergency department visit, which Medicare pays through a level-specific APC under the outpatient payment system. The emergency physician bills a professional fee under the Physician Fee Schedule using the same 99281 to 99285 code. Each has its own level and its own bill.
What does Medicare pay for a level 5 ER visit?
For CY2026, the Medicare anchors are $608.43 for the hospital facility side (APC 5025, national unadjusted, before wage-index adjustment) and $181.58 for the physician's professional fee (Michigan Locality 01). These are Medicare payment anchors, not what a hospital charges a self-pay patient.
What does a person with Medicare pay for an ER visit?
Under Part B, the hospital copayment is figured on the outpatient payment and the physician coinsurance on the fee schedule amount, after the Part B deductible ($283 in 2026). The CY2026 minimum unadjusted hospital copayment for a level 5 visit is $121.69. Medicare.gov says no single outpatient service copayment can exceed the inpatient hospital deductible.
Can I ask why my visit was billed at a higher level?
Yes. Ask the hospital billing office and the physician group separately for the level billed on each claim and the documentation that supported it. You can also request your medical record for the visit. A level is a coding decision, and coding questions are billing questions.
Are all emergency departments paid at the same Medicare rates?
No. The CMS outpatient addenda list a second set of emergency payment groups, Type B (APCs 5031 to 5035), at lower Medicare rates than Type A (APCs 5021 to 5025). Which set applies depends on how the facility bills, so ask the facility before relying on a price.
Data and rules behind the anchors
- CMS, OPPS quarterly addenda, October 2026 Addendum A (APC payment rates and minimum unadjusted copayments for APCs 5012, 5021 to 5025, 5031 to 5035, 5041) and Addendum B (99281 to 99285 assigned to APCs 5021 to 5025 with status indicator J2; G0380 and G0384; G0463). Checked October 22, 2026.
- CMS, Physician Fee Schedule relative value file RVU26D (October 2026 release) and CY2026 geographic practice cost indices, Michigan Locality 01, with the $33.4009 conversion factor; descriptions of 99281 to 99285 by level of medical decision making. The same calculation reproduces the WPS GHA anchors used elsewhere on this site. Checked October 22, 2026.
- CMS, 2026 Medicare Parts A & B premiums and deductibles; Medicare.gov, Inpatient or outpatient hospital status. Checked October 22, 2026.
- CMS, Medical bill rights: explanation of benefits, No Surprises Help Desk number. Checked October 22, 2026.
Prices only. No diagnosis or treatment advice. If you believe you have a medical emergency, call your local emergency number or go to the nearest emergency department. Medicare anchors are not your bill; confirm any price in writing when you can.
If your visit included a scan, the scan is billed on its own line; looking up a procedure price by its CPT code shows the Medicare anchor for the code on that line, so you can judge the rest of the bill.