Most people know the ER is costly, but many don’t realize just how much the visit level affects the final bill. If you’ve ever seen “Level 4” or “Level 5” on your statement—or CPT codes 99284 or 99285—you may be wondering why these charges are so high and whether they were applied correctly.
ER visit levels are meant to reflect the complexity of your condition and the decision-making required to treat you. But in many hospitals, these levels are used inconsistently, over-applied, or misunderstood, leading to inflated bills and confusion for patients. Here’s what these levels really mean, why they’re so expensive, and what to do if you think you were overcharged.
What ER Visit Levels Actually Mean
Emergency departments classify visits from Level 1 (lowest complexity) to Level 5 (highest complexity). The level is supposed to reflect:
- The severity of your condition
- The number of tests or interventions required
- The level of medical decision-making
- The potential risk to your health
In general:
- Level 1–2: Minor issues, minimal testing
- Level 3: Moderate symptoms requiring labs or imaging
- Level 4–5: High-risk or complex issues requiring extensive evaluation
But the definition of “complex” is subjective—and that’s where problems begin.
Why Levels 4 and 5 Cost So Much
1. Higher Facility Fees
Facility fees increase dramatically with each level. A Level 4 or 5 visit may be billed at two to three times the cost of a Level 3 visit—even if your care didn’t feel significantly different.
2. Documentation Drives Billing
The more detailed the provider’s note, the higher the level they can justify. In many ERs, electronic templates automatically add language that makes visits appear more complex on paper than they were in reality.
3. Corporate ER Groups Rely on Higher Coding
Many emergency rooms are operated by corporate staffing companies. These groups emphasize higher-level coding to maximize reimbursement, which has caused a nationwide surge in Level 4 and 5 billing.
4. Defensive Medicine
Providers often order extra tests “just in case,” especially when symptoms are uncertain. More tests = higher complexity = higher level.
5. Automated Systems Inflate Complexity
Electronic health record checkboxes can unintentionally upcode a visit, reflecting more risk than what actually occurred.
Together, these factors can turn a simple ER visit into a costly one—without the patient realizing why.
Signs Your Visit Was Coded Too High
Not every Level 4 or 5 bill is wrong. But many are. Here are the most common indicators your visit may have been overcoded:
1. Your symptoms were mild
Examples: ear pain, headache, dehydration, minor injury, medication reaction, or abdominal discomfort without complications.
2. You received minimal testing
A true Level 4 or 5 visit typically involves extensive labs, imaging, or multiple interventions. If you only had a basic exam or one test, the level may not match.
3. Your visit was quick
High-complexity cases usually take time—evaluation, monitoring, treatment planning. If you were seen briefly and discharged fast, the level may be inflated.
4. The documentation doesn’t match your experience
Sometimes records include statements like “high risk of deterioration” even when your visit was stable and straightforward.
5. Your Rapid Medical Evaluation (RME) inflated the level
RME providers often order tests early to reduce wait times, but these tests can unintentionally push your visit into a higher billing category.
Why This Happens So Often
Hospitals and providers often defend their coding decisions by emphasizing risk—even if the diagnosis ended up being minor. If there was any possibility of a serious condition, they may claim a high-level evaluation was justified.
Additionally:
- Providers rely heavily on templates
- Coding departments push for higher levels
- Corporate groups incentivize high-complexity billing
Patients rarely question these charges, even when the coding doesn’t match the care.
How to Check if Your Visit Level Is Accurate
You don’t need medical training for this. Follow these simple steps:
1. Request your itemized bill and medical records
Look for CPT codes 99284 and 99285. Then compare what’s documented to what you actually experienced.
2. Review what tests and treatments were done
Minimal testing usually doesn’t support a Level 4 or 5 charge.
3. Compare your bill to your Explanation of Benefits (EOB)
Your EOB shows exactly what was billed and what insurance accepted or rejected.
4. Look for copy-paste or generic documentation
If the note doesn’t reflect your real visit, it may have artificially elevated your visit level.
What to Do If You Think You Were Upcoded
If your care didn’t match a Level 4 or 5 visit, you can take action:
1. Ask the hospital for a coding review
Request an explanation in writing.
2. Question charges that don’t align with your symptoms
Ask why certain tests or evaluations were required.
3. Ask for a corrected bill
If the hospital cannot justify the level, they must revise it.
4. Get expert help
This is where ER Watchdog provides the most value.
We:
- Review your medical records and bill
- Identify upcoding, duplicate charges, or inflated fees
- Explain what should have been billed
- Help you challenge inaccurate charges
Don’t Pay a Level 4 or 5 Charge Until You Understand It
High-level ER coding can significantly inflate your bill—and many hospitals rely on patients not knowing what these levels mean. If your symptoms were mild, your visit was short, or your testing was minimal, there’s a real chance your visit was coded too high.
Before paying, upload your ER bill to ER Watchdog for a free review.
We’ll tell you exactly what happened, what the hospital charged, and whether it’s correct.
You deserve clarity. You deserve fairness. And you shouldn’t pay for care you didn’t receive.