The Complete Guide to E/M Coding 2025–2026

The Current Framework: What Changed in 2021 and Why It Still Matters

January 1, 2021 marked the most significant revision to Evaluation and Management coding since the 1995 Documentation Guidelines. CMS and the AMA eliminated history (HPI, ROS, PFSH) and physical examination as code level determinants for office visit E/M codes. In their place, the code level is determined exclusively by Medical Decision Making (MDM) complexity or total time.

This matters in 2025–2026 because many practices have not fully internalized the change. Physicians still write extensive review-of-systems documentation out of habit—documentation that has zero impact on code level under the current guidelines. That is wasted documentation time. Simultaneously, some practices are under-coding because they do not understand how to apply MDM analysis correctly.

The Code Sets: A Complete Reference

New Patient Office Visits (99202–99205)

New Patient Office Visit Codes 2025–2026

Code	MDM Level	Time	2026 Medicare Rate (national, non-facility)
99202	Straightforward	15–29 min	~$77
99203	Low	30–44 min	~$112
99204	Moderate	45–59 min	~$167
99205	High	60–74 min	~$211

Established Patient Office Visits (99211–99215)

Established Patient Office Visit Codes 2025–2026

Code	MDM Level	Time	2026 Medicare Rate (national, non-facility)
99211	N/A (nurse visit)	<10 min	~$25
99212	Straightforward	10–19 min	~$58
99213	Low	20–29 min	~$92
99214	Moderate	30–39 min	~$136
99215	High	40–54 min	~$180

Medical Decision Making: The Four Levels

Straightforward MDM

All three elements at the minimal/straightforward level:

• Problems: Minimal (one self-limited or minor problem)
• Data: Minimal or none
• Risk: Minimal (OTC drug management or rest/bandaging)

Examples: Wart treatment, annual flu shot visit with no problems addressed, minor lacerations with suturing.

Low MDM

Two of three elements at low complexity:

• Problems: Two or more self-limited problems, OR one stable chronic illness
• Data: Limited data review (review of prior external note OR ordering of a test)
• Risk: Low (prescription drug management; minor surgery without identified risk factors)

Examples: Hypertension follow-up with refill, stable thyroid management, URI with antibiotic prescription.

Moderate MDM

Two of three elements at moderate complexity:

• Problems: One or more chronic illnesses with exacerbation/progression, OR one new undiagnosed problem with uncertain prognosis, OR two or more stable chronic illnesses, OR one acute illness with systemic symptoms
• Data: Moderate (meets Category 1, 2, or 3 criteria—see detailed breakdown below)
• Risk: Moderate (prescription drug management; elective major surgery without identified risk factors; diagnosis or treatment significantly limited by social determinants)

High MDM

Two of three elements at high complexity:

• Problems: One or more chronic illnesses with severe exacerbation, OR one acute or chronic illness or injury that poses a threat to life or bodily function
• Data: High (review of extensive data; Category 3 requiring independent interpretation; discussion requiring independent management decision)
• Risk: High (drug therapy requiring intensive monitoring for toxicity; elective major surgery with identified risk factors; emergency major surgery; decision not to resuscitate; hospitalization)

The Moderate MDM Data Category in Detail

The Moderate MDM Data element is the most frequently misunderstood. It requires meeting at least one of three categories:

Category 1 (combination): Must meet at least 3 of the following 5 elements:

1. Review of prior external note(s) from each unique source
2. Review of the result(s) of each unique test
3. Ordering of each unique test
4. Assessment requiring independent interpretation (you interpret a result, not just review the report)
5. Assessment requiring an independent historian

Category 2: Assessment requiring independent interpretation of a test performed by another physician (e.g., you personally interpret an EKG, not just review the cardiology report).

Category 3: Discussion of management or test interpretation with external provider, including telephone or electronic communication (document the date, provider, and content of the discussion).

Time-Based Coding: The Documentation Requirements

Time-based coding eliminates MDM analysis entirely—if you document total time accurately, that is sufficient to justify the code level. Requirements:

• Document the total time spent on the date of service
• Total time includes: pre-visit chart review, the face-to-face encounter, post-visit ordering, documentation, referral coordination on the same calendar date
• Does NOT include: nursing/MA time, time on other days
• Must be the physician or qualified non-physician practitioner's time
• A brief description of activities counted toward total time is best practice (reduces audit risk)

Example documentation: "Total time for encounter date 8/8/2026: 35 minutes, including 8 minutes pre-visit chart review, 22 minutes face-to-face with patient, 5 minutes post-visit lab ordering and referral letter."

Telehealth E/M Codes

Since 2020, CMS has made telehealth office visit codes permanently available for established patients and extended them for new patients through Congressional action. The same 99202–99215 codes apply; payers add a modifier (typically GT for interactive video or 95 for synchronous telehealth) and a place of service code (POS 02 for telehealth outside the patient's home, POS 10 for telehealth in patient's home).

MDM and time-based coding apply identically to telehealth visits. Audio-only visits have additional restrictions—most payers require interactive two-way audio-video for full E/M reimbursement; audio-only may be billed under G2252 (Medicare) with appropriate modifier.

Add-On Codes That Increase Revenue Without Upcoding

• 99417: Prolonged office visit services, each 15 minutes beyond 99215 (55+ total minutes). Use when a single encounter legitimately runs 55 minutes or more. Document total time.
• G2211: Medicare complexity add-on for primary care. Added to 99202–99215 when you are the primary care physician or the patient's focal point for ongoing care. Worth approximately $16 per visit when applicable—meaningful for high-volume primary care panels.
• 99429 / 99497: Advance care planning (ACP). Bill separately when conducting ACP discussions with patients 65+ about code status, advance directives, healthcare proxies. Document the discussion content and patient's expressed preferences.

Audit Risk Management

OIG Work Plans consistently identify E/M coding as a high-audit priority. Key risk areas:

• All visits coded at 99215 or 99214—statistically improbable distribution that triggers payer audits
• Time-based billing without time documented in the note
• MDM claims that exceed what the note supports (claiming moderate data review with no documented test review)
• Copy-paste notes where every visit has identical documentation

Best practice: run a quarterly internal audit of a random sample of 20–30 charts. Verify that your documented MDM or time supports the billed code level for each sampled visit. Correct patterns before a payer audit finds them.

E/M Coding and AI Documentation

AI ambient documentation naturally generates notes that reflect the clinical content of the encounter—including the problems addressed, tests reviewed, and clinical decisions made. This content maps directly to MDM elements. An AI-native EMR can analyze the generated note and suggest the appropriate E/M code level with citations to specific note content. This is not automatic upcoding; it is a verification that the billed level is supported by the documented clinical work.

See Krasyn's billing review workflow to understand how AI-assisted E/M level suggestion works in practice.