CPT code 99285: ED visit, high complexity decision making2026 Medicare rate & RVUs in Illinois
High-level emergency department evaluation reported when the physician or qualified health care professional's assessment and management meet high medical decision-making requirements.
CMS doesn’t publish an office rate for 99285 in Illinois.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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What 99285 covers
Emergency physicians and qualified health care professionals use this level for emergency department assessments involving high medical decision making. Chest pain concerning for acute coronary syndrome, new focal neurologic deficits, suspected sepsis, and acute respiratory distress may prompt complex diagnostic and disposition decisions, but the presentation alone does not establish the level. The service includes a clinically appropriate history and examination in a hospital emergency department; it does not depend on whether the patient is new or established.
Select this level when at least two of three medical decision-making elements—problems addressed, data reviewed and analyzed, and management risk—meet the high threshold. High data complexity requires two qualifying data categories, such as independent test interpretation plus discussion of management with an external clinician; a hospitalization decision can support high risk. Document the problems addressed, relevant orders or results, data analysis, and treatment or disposition decisions. Time does not determine the ED visit level. If the same practitioner also furnishes initial inpatient or observation care that date, report only the initial hospital care service. A distinct earlier ED visit may be reported with subsequent critical care when separately documented.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 99285 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Chicago, IL | Unavailable | $193.15 |
| East St. Louis, IL | Unavailable | $185.87 |
| Rest of Illinois | Unavailable | $178.48 |
| Suburban Chicago, IL | Unavailable | $185.25 |
How the 99285 rate is calculated
Each of 99285’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 99285
RVUs × geographic indexes × conversion factor
Work4.00
4.00 RVUs× 1.000 GPCI
Practice expense0.65
0.65 RVUs× 1.000 GPCI
Malpractice0.48
0.48 RVUs× 1.000 GPCI
Adjusted RVUs
5.1300
Conversion factor
$33.4009
Medicare rate
$171.35
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 99285
99285 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.
Place of service · 99285
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
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99285 isn’t priced in this setting.
99285 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 99284Emergency department visitModerate medical decision making
- Choose 99285 when at least two MDM elements meet the high threshold. A life-threatening problem or hospitalization decision can support one element; moderate MDM supports 99284.
- 99291Critical careInitial service, at least 30 minutes
- Critical care requires at least 30 minutes of qualifying care for critical illness or injury with a high probability of imminent or life-threatening deterioration. Code 99285 is selected by MDM, not time.
- 99223Initial hospital visitHigh decision making or 75 minutes
- When the same practitioner provides an ED visit and initial inpatient or observation care on the same date, report initial hospital care rather than both services; use 99223 only when its level criteria are met.
- 99283Emergency department visitLow medical decision making
- Code 99283 reflects low medical decision making in the ED. Code 99285 requires high complexity in at least two MDM elements, regardless of visit duration.
99285 billing questions
Can time be used to support this level?
No. ED visits are leveled by medical decision making, so a long stay alone does not support 99285. Documentation must establish high complexity in at least two of the three MDM elements.
What distinguishes this level from the moderate-complexity ED visit?
Choose 99285 when at least two MDM elements meet the high threshold; an acute threat to life or a hospitalization decision can support one element but does not establish the level alone. Choose 99284 when the documented MDM is moderate.
Can critical care be reported on the same date by the same provider?
Yes, if a medically necessary ED visit occurs before the patient requires critical care and the services are distinct. Append modifier 25 to the ED visit, document the separate services, and exclude the visit's work from critical care time.
What happens if the ED physician admits the patient?
When the same practitioner provides the ED service and initial inpatient or observation care on the same date, report only the initial hospital care service. Practitioners in the same group and specialty are treated as the same physician for this purpose.
Is ECG interpretation bundled into this visit?
A medically necessary, separately documented ECG interpretation and report may be reported with 93010. An interpretation billed separately cannot also count as independent test interpretation in the visit's data element.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
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