Trends in Emergency Department Exam Medicare Reimbursements Between 2010 and 2018

As the Medicare population continues to grow, financial pressure is placed upon hospitals, physicians, and other providers as the payer mix has an increasing proportion of Medicare patients.

The purpose of this study was to further the understanding of reimbursement trends surrounding the five levels of emergency department (ED) examinations (CPT codes 99281-99285) from 2010 to 2018 and determine how they have changed with respect to each procedure.

CPT codes were filtered into the 2010 and 2018 Physician/Supplier Procedure Summaries from the Centers for Medicare and Medicaid Services' website to gather data on emergency physician submissions and Medicare denials and payments.

In 2010, 15,669,196 ED examinations were submitted to Medicare for $7,628,693,382 while in 2018, 16,432,184 ED examinations were submitted for $14,522,456,383. Despite an increase of $397/submission made by emergency physicians, Medicare paid 20.5% of the submitted charges in 2010 for ED examinations and 11.9% in 2018. The denial rate in 2018 was highest for level I ED examinations (11.3%), and the lowest for level V examinations (5.1%). The utilization of level V ED examinations increased 22.3% from 2010 to 2018, while the utilization of the others decreased. Of the five levels of ED examinations, only the level I examination did not exhibit a decrease.

From 2010 to 2018, emergency physicians charged a higher amount for ED examinations, yet Medicare reimbursement accounted for a smaller proportion of these charges, resulting in less payment per submission for the four most common levels. Downward trends in Medicare reimbursement may place financial burdens that could potentially hamper healthcare outcomes.