E/M Coding GuidelinesComplete Documentation Guide
Master evaluation and management coding with the latest 2025-2026 guidelines. Learn medical decision-making levels, time-based coding, and documentation requirements to maximize revenue while staying compliant.
What Changed in 2024-2025?
Recent updates have significantly impacted how practices document and code E/M services.
Time Thresholds
Time ranges removed. Now you must meet or exceed minimum time thresholds for each code level.
G2211 Add-On
New ~$16-17 add-on code for longitudinal primary care visits. Available with 99202-99215.
16 New Telehealth Codes
Codes 98000-98015 for telehealth. COVID-19 flexibilities expired; pre-pandemic rules restored.
Split/Shared Visits
Provider performing "substantive portion" bills service. Based on >50% time or MDM ownership.
E/M Code Reference Table
Quick reference for office/outpatient E/M codes 99202-99215 with MDM levels and time thresholds.
| CPT Code | Patient Type | MDM Level | Time | Typical Scenario |
|---|---|---|---|---|
| 99202 | New Patient | Straightforward | 15-29 min | Self-limited problems, minimal data, minimal risk |
| 99203 | New Patient | Low | 30-44 min | 2+ self-limited problems OR 1 chronic stable, limited data |
| 99204 | New Patient | Moderate | 45-59 min | 1+ chronic with exacerbation OR 2+ chronic stable, moderate data |
| 99205 | New Patient | High | 60-74 min | 1+ chronic with severe exacerbation OR acute life-threatening |
| 99211 | Established | N/A (May not require physician) | — | Minimal problem, typically 5 minutes or less |
| 99212 | Established | Straightforward | 10-19 min | Self-limited problems, minimal data, minimal risk |
| 99213 | Established | Low | 20-29 min | 2+ self-limited problems OR 1 chronic stable |
| 99214 | Established | Moderate | 30-39 min | 1+ chronic with exacerbation OR undiagnosed new problem |
| 99215 | Established | High | 40-54 min | 1+ chronic with severe exacerbation OR acute life-threatening |
Pro Tip: You can select code level based on either MDM OR time—whichever supports the higher level. Most practices use MDM as it's more intuitive and doesn't require tracking minutes.
Medical Decision-Making (MDM) Levels
MDM is determined by meeting 2 of 3 elements at a given level. Here's what qualifies for each complexity.
| Element | Straightforward | Low | Moderate | High |
|---|---|---|---|---|
| Problems Addressed | 1 self-limited or minor problem | 2+ self-limited problems OR 1 stable chronic illness | 1+ chronic illness with exacerbation OR undiagnosed new problem with uncertain prognosis | 1+ chronic with severe exacerbation OR acute illness posing threat to life or function |
| Data Reviewed | Minimal or none | Limited (review of external notes, ordering tests) | Moderate (independent interpretation, discussion with external physician) | Extensive (independent interpretation of complex test, discussion with external physician) |
| Risk of Complications | Minimal risk of morbidity | Low risk (OTC drugs, minor surgery with no risk factors) | Moderate risk (Rx drug management, minor surgery with risk factors) | High risk (drug therapy requiring intensive monitoring, major surgery) |
What Counts Toward MDM
- • Problems actively addressed during the visit
- • Independent interpretation of tests you performed
- • Discussion with external physician about management
- • Prescription drug management decisions
- • Comorbidities that affect current treatment
What Doesn't Count
- • Reviewing results already interpreted by radiologist
- • Comorbidities not addressed at this visit
- • Problems mentioned but not managed
- • Discussion with staff (not external physicians)
- • Time spent on administrative tasks
Time-Based Coding
When selecting codes based on time, document total time spent on the date of encounter. Here's what activities count toward total time.
Activities That Count
Activities That Don't Count
Time Documentation Example
"Total time spent on date of encounter: 35 minutes. Time included chart review, face-to-face examination, medication reconciliation, counseling patient on treatment options, and documentation in EHR."
Common E/M Coding Mistakes
Avoid these frequent errors that lead to revenue loss, audit flags, and compliance issues.
Under-coding due to fear of audits
Revenue loss of 10-30%
Document MDM thoroughly; if documentation supports higher level, bill for it
Over-relying on template cloning
Audit flags, potential fraud allegations
Customize each note; document specific changes in patient condition
Missing time documentation for time-based visits
Downcoding or denial
Document total time spent and activities performed on date of service
Not counting comorbidities in MDM
Under-coding complexity
Only count comorbidities if they affect the current visit management
Incomplete data documentation
Cannot support moderate/high MDM
Document independent interpretation, external physician discussions
Ignoring G2211 add-on eligibility
Missing $16+ per qualifying visit
Bill G2211 for ongoing longitudinal care relationships
2026 Audit Landscape: What You Need to Know
CMS is dramatically expanding audit capacity. Here's what's changing and how to prepare.
Key 2026 Audit Changes
Scoring removed from audits—no more point values for conditions
Simple fixes verified directly by CMS without full validation audit
>5 complex findings requires independent auditor validation
All claims audits must include clinician review (not just coders)
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Frequently Asked Questions
Common questions about E/M coding and documentation.
QWhat changed in E/M coding for 2025?
The 2025 guidelines introduced 16 new telehealth E/M codes (98000-98015), aligning telehealth documentation requirements with in-person visits. COVID-19 flexibilities expired, returning telehealth to pre-pandemic rules. A new code G5045 was introduced for inpatient observation services.
QShould I use time or MDM for code selection?
You can use either, but most practices prefer MDM because it's based on clinical complexity rather than tracking minutes. Time-based coding is useful for counseling-heavy visits where you spend significant time discussing options but the clinical decision is straightforward.
QWhat is G2211 and when should I bill it?
G2211 is a Medicare add-on code (~$16-17) for office visits with ongoing primary care or longitudinal relationships. You can bill it with 99202-99215 when you provide continuous care for a patient's condition(s) over time, not just episodic visits.
QCan I bill for the same patient twice in one day?
Yes. For same-day visits, aggregate the MDM elements across both encounters to determine the code level, or sum the time spent. For admission and discharge on the same day (stays >8 hours), use codes 99234-99236.
QHow do split/shared visits work in 2024-2025?
For split/shared E/M services between a physician and QHP, the provider who performs the "substantive portion" bills the service. If using time, the provider spending >50% of total time reports. If using MDM, whoever addresses the problems and manages risk reports.
QWhat documentation is required for moderate MDM?
You need 2 of 3 elements at moderate level: (1) 1+ chronic illness with exacerbation OR undiagnosed new problem, (2) Moderate data review (independent interpretation OR external physician discussion), (3) Moderate risk (Rx drug management, minor surgery with risk factors).
QHow do I document time correctly for time-based billing?
Document total time spent on the date of encounter, including both face-to-face and non-face-to-face activities. List specific activities performed. The 2024 changes removed time ranges—you must now meet or exceed the minimum threshold for each code.
QWhat's the biggest audit risk in E/M coding?
Clone documentation (identical or near-identical notes across visits) is the highest audit risk. CMS and OIG specifically target practices with repetitive templates. Each note should reflect the unique aspects of that specific encounter.