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Emergency Room

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Emergency Room Receipt Example

This receipt documents a Level 3 ER visit at Northwestern Memorial Hospital. The $850.00 billed amount is reduced by a $340.00 contractual adjustment to an allowed amount of $510.00. Of that, $250.00 applies to the remaining annual deductible (patient pays 100%), and $260.00 enters the 20% coinsurance phase (patient pays $52.00, insurance pays $208.00). Total patient responsibility: $302.00.

This emergency room receipt documents a level-3 ER visit (CPT 99283) with facility fee ($1,250) and professional fee ($385) for a total bill of $1,635, with $1,235 insurance adjustment and $400 patient responsibility after deductible.

Receipt Breakdown

CPT 99283: Emergency Dept Visit, Level 3$850.00
Contractual Adjustment−$340.00
Allowed Amount$510.00
Deductible Applied (remaining annual)$250.00
Amount Subject to Coinsurance$260.00
Patient Coinsurance (20%)$52.00
Insurance Paid (80% coinsurance)−$208.00
Patient Responsibility$302.00
ICD-10M54.5

What Makes This Receipt Realistic

  • • Full deductible + coinsurance breakdown, both components shown separately
  • • CPT 99283: Level 3 ER code, appropriate for moderate-severity problems
  • • Deductible labeled as "remaining annual", reflects partial-year scenario
  • • $850.00 billed, realistic facility fee for a Level 3 ER visit
  • • Math: $510.00 − $250.00 = $260.00 coinsurance base; $260.00 × 20% = $52.00; $250.00 + $52.00 = $302.00
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Chest X-ray technical + radiologist read: $50.00

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Frequently Asked Questions

What does this emergency room receipt show?

This receipt documents an ER visit at Northwestern Memorial Hospital Emergency Department, 251 E. Huron St, Chicago, IL 60611. Patient: Daniel R. Okafor. Date of Service: November 18, 2025. CPT 99283: Emergency Department Visit, Level 3 (moderate severity). ICD-10: M54.5 (Low back pain). Billed: $850.00. Contractual Adjustment: −$340.00. Allowed Amount: $510.00. Deductible Applied (remaining annual deductible): −$250.00. Amount Subject to Coinsurance: $260.00. Patient Coinsurance (20%): $52.00. Total Patient Responsibility: $302.00. Insurance Paid: $208.00.

How does the deductible and coinsurance work on this ER receipt?

When the annual deductible has not been fully met, the patient pays 100% of the allowed amount until the deductible is satisfied. In this receipt, $250.00 of the $510.00 allowed amount applies to the remaining deductible, the patient owes the full $250.00. The remaining $260.00 ($510.00 − $250.00) enters the coinsurance phase, where the patient pays 20% ($52.00) and insurance pays 80% ($208.00). Total patient responsibility: $250.00 (deductible) + $52.00 (coinsurance) = $302.00. Once the deductible is fully met, future claims skip directly to coinsurance.

What is CPT 99283 and how are ER visit levels determined?

Emergency department visits are coded CPT 99281–99285 based on the severity and complexity of the presenting problem. CPT 99281 is the lowest (minor problems), CPT 99285 is the highest (high complexity, life-threatening). CPT 99283 (Level 3) covers moderate severity problems, problems where the patient may require additional work-up, have multiple diagnoses, or require prescription medication to manage. A back pain visit that requires imaging review and prescription pain management would typically be coded at Level 3. The ER facility and the treating physician may bill separately, this receipt covers the facility fee; a separate physician billing receipt may arrive from the emergency medicine group.