Reimbursement
$117.57
Threshold
N/A
2026 Status
Active
What is CPT Code 99284?
CPT 99284 is defined as: Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level medical decision making. Typically involves severe symptoms or high risk of morbidity, but no immediate threat to life.
This code is primarily used for E/M services. It falls under the category of Hospital Inpatient/Observation & Emergency Department and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
2.74
Physician Effort
PE (Non-Fac)
0.56
Practice Expense
Malpractice
0.22
Risk Factor
Total RVU
3.52
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
complexity incentive
wRVU of 2.74 recognizes the high diagnostic and management intensity required for serious ED presentations.
efficiency shield
Exempt from -2.5% efficiency cut.
facility tiering
Often corresponds to Level 4 or 5 hospital facility charges.
Administrative Framework
Global Period
000
Place of Service
NCCI Exclusions
Operational Requirements
minimum time
Not time-based
staff type
Physician or other Qualified Health Care Professional (QHP)
frequency
Per encounter
add on codes
care plan requirement
High medical decision making involving complex differential diagnosis and management of severe symptoms.
Compliance Checklist
Audit Defense
No specific audit defense elements defined.
2026 Update
High-risk social determinants of health (SDOH) can now contribute to the 'risk' element of MDM for 99284 – ensure SDOH factor is documented.
Common Clinical Scenarios
CMS Eligibility: 1+ acute illness with high risk of morbidity or 1 acute worsening of severe chronic illness. Acute
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Billing Differentiation
VS 99283
99283 is moderate; 99284 is high MDM.
VS 99285
99285 involves 'immediate' threat to life or function.
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