The Complete E/M Coding Guide for 2026: MDM vs Time, Code by Code

Since the 2021 AMA E/M overhaul, every office and outpatient E/M code (99202 to 99215) is selected by either Medical Decision Making (MDM) or Total Time on the date of service. You pick whichever produces the higher level. That is the only rule. History and exam are no longer scoring elements. They still need to be documented for clinical and medical-legal reasons but they do not affect code selection. The CY 2026 CMS Physician Fee Schedule preserves this two-path framework. Time thresholds, MDM elements, and code definitions are unchanged from the 2021 baseline. The practical implication: if your providers are still selecting E/M codes by counting bullet points (history elements, exam systems, PFSH), you are operating on stale guidance and almost certainly under-coding moderate-complexity visits while over-coding routine ones.

Element one: Number and Complexity of Problems Addressed. Self-limited or minor is Minimal. One stable chronic illness or one acute uncomplicated illness is Low. Two or more stable chronic illnesses, one chronic illness with exacerbation, one undiagnosed new problem with uncertain prognosis, one acute illness with systemic symptoms, or one acute complicated injury is Moderate. 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 is High. Element two: Amount and Complexity of Data Reviewed and Analyzed. Data falls into three categories: tests/documents/independent historian, independent test interpretation, and discussion with another external healthcare professional. Each level requires a specific combination. Element three: Risk of Complications, Morbidity, or Mortality of Patient Management. Minimal is no medication management. Low is OTC drug management or minor surgery without identified risk factors. Moderate is prescription drug management, decision regarding minor surgery with patient or procedure risk factors, decision regarding elective major surgery without identified risk factors, or treatment significantly limited by social determinants of health. High is decision regarding elective major surgery with risk factors, emergency major surgery, hospitalization, drug therapy requiring intensive monitoring, or do-not-resuscitate decision.

Total Time on the date of service captures everything the billing provider personally does for that patient on that date: pre-visit chart review, the encounter itself, ordering tests and prescriptions, documenting, communicating with the patient or family, coordinating with other providers. It does NOT include time spent by clinical staff, time on activities not related to the patient's care that day, or time on the day before or after. 2026 office visit time thresholds: 99202 (15-29 min new), 99203 (30-44 min new), 99204 (45-59 min new), 99205 (60-74 min new), 99212 (10-19 min established), 99213 (20-29 min established), 99214 (30-39 min established), 99215 (40-54 min established). Documentation requirement: a specific time entry with what filled the time. 'Total time on date of service: 33 minutes including chart review, encounter, ordering follow-up labs, and documentation' passes audit. 'Spent additional time' fails.

A new patient is one who has not received any professional services from the physician or another physician of the same specialty in the same group practice within the past three years. 99202: Straightforward MDM OR 15-29 minutes total. 99203: Low MDM OR 30-44 minutes; most common new patient code in primary care. 99204: Moderate MDM OR 45-59 minutes; right code for new patients with multiple chronic conditions or one undiagnosed problem requiring workup. Common in cardiology, GI, neurology, oncology. 99205: High MDM OR 60-74 minutes; for severe exacerbation or threat to life or bodily function. Specialty benchmark: cardiology, GI, neurology, oncology should bill 99204 or 99205 on the majority of new patient encounters. Practices defaulting new patients to 99203 are frequently under-coding. See our deep dive at /blog/99213-vs-99214-when-to-bill-each for established-patient detail.

99211: Minimal level visit, typically nurse-only encounters. 99212: Straightforward MDM OR 10-19 minutes; brief visits for stable simple problems. 99213: Low MDM OR 20-29 minutes; the historical workhorse. 99214: Moderate MDM OR 30-39 minutes; the right code for the majority of established cardiology, neurology, GI, endocrinology, and pulmonology follow-ups. 99215: High MDM OR 40-54 minutes; for severe exacerbation or complex management. Specialty benchmarks: primary care should bill 99214 on roughly 35 to 50 percent of established visits. Cardiology and other complex specialties should bill 99214 on 60 to 70 percent. Practices billing 99214 at less than 25 percent in primary care or less than 50 percent in cardiology are almost certainly under-coding. Use /tools/cpt-lookup for current 2026 RVU and payment.

ED E/M codes are MDM-only. Time is not a scoring element. 99281: Self-limited or minor problem; rarely billed in modern ED. 99282: Straightforward MDM. 99283: Low MDM; routine acute problems with focused workup. 99284: Moderate MDM; the workhorse of ED billing for acute illness with systemic symptoms or undiagnosed problem with uncertain prognosis. 99285: High MDM; severe presentations with high risk (chest pain workup involving stress test or hospitalization, sepsis, major trauma, suicide risk). ED E/M downcoding is a major audit target for hospital-based emergency physicians. Documentation must explicitly map to the MDM elements, particularly Risk: hospitalization decisions, high-acuity drug therapy, and threat-to-life judgments must be in the chart. ED leveling also interacts with state payer rules: our Texas emergency room billing and Oklahoma emergency room billing pages cover the Medicaid managed care, prompt pay, and out of network specifics for emergency groups in those states.

Inpatient and observation services were consolidated in 2023; both use the same code set. 99221, 99222, 99223 cover initial hospital or observation care (Low/Moderate/High MDM). 99231, 99232, 99233 cover subsequent hospital or observation care. 99238, 99239 cover discharge day management (under or over 30 minutes). Selection turns on MDM only for initial and subsequent codes. Time is the discriminator for discharge codes. Common gap: failing to document the level of severity that supports 99223 when warranted; defaulting subsequent visits to 99232 when the case was either lower acuity (99231) or actually involved high MDM (99233). CMS CERT data shows inpatient E/M selection accuracy below 80 percent across most reviewed specialties.

Preventive medicine codes are age-banded comprehensive preventive evaluations. 99381-99387 cover new patient by age band; 99391-99397 cover established patient by age band. 99391-99397 are higher volume in primary care. Common scenario: a preventive visit on the same date as a problem-focused E/M (the annual physical where the patient also reports a new complaint requiring workup). Both are billable when documentation supports both. The problem E/M gets modifier 25 to indicate a significant separately identifiable service. Document the preventive elements (age-appropriate counseling, screening, anticipatory guidance) distinctly from the problem-focused work. Common payer pattern: Medicare does not cover preventive medicine codes 99381-99397 directly; use G0438 (initial Annual Wellness Visit) or G0439 (subsequent AWV) for Medicare patients.

Modifier 25 is appended to an E/M code when a significant separately identifiable E/M service is provided on the same date as a procedure with a 0 or 10 day global period. It is the most-audited E/M modifier in physician billing. The OIG and CMS CERT have repeatedly identified inappropriate modifier 25 application as a focus area. Documentation requirements: the E/M must address something beyond the routine pre-procedure evaluation that would normally be bundled, the chart should clearly establish a distinct chief complaint or HPI section addressing problems unrelated to the procedure indication, and the assessment and plan should have separable E/M elements. Best practice: structure the note so the E/M section visually precedes and is distinct from the procedure note. See /blog/modifier-25-audit-survival-guide for the complete framework. Use /tools/modifier-finder for scenario-based modifier guidance.

When you bill an E/M code via the Time path, the documentation must support both that you spent the time and what filled the time. Three patterns that work. Pattern one: contemporaneous time log. At the bottom of every Time-path encounter, document a specific time entry with categorized activities. 'Total time on date of service: 36 minutes. Pre-visit chart review (8 min), face-to-face encounter (18 min), ordering follow-up labs and care coordination call (6 min), documentation (4 min).' Pattern two: time tracking via EHR template that prompts for time entry at close of encounter. Pattern three: consistency between time and complexity. A 99214 billed via Time should not have a five-line assessment and plan suggesting the visit took 10 minutes. Pattern that fails: vague phrases like 'extended time' without specific minutes. Audit teams treat unsupported time documentation as evidence of upcoding.

Major commercial payers including UnitedHealthcare, Anthem, Cigna, and several BCBS plans run automated E/M downcoding algorithms that compare the billed level against documentation language and against the provider's billing pattern relative to specialty peers. Practices that bill 99214 at significantly higher rates than peers in the same specialty get flagged. Practices with vague chart language at the documentation point get downcoded by default. The defense is uniform: documentation that explicitly maps to the 2021 MDM elements or to a specific stated total time on the date of service. When chart language matches the billed level, the algorithm passes. When the chart is vague, the algorithm downcodes. Practices that have moved to structured note templates aligned to MDM scoring see their downcoding rate drop within 60 to 90 days.

E/M coding is where most of the under-captured office revenue lives. Our AAPC-certified coders pre-scrub every E/M claim against the documentation, query providers when documentation does not match the billed level, and apply optimal modifier strategies when same-day procedures are involved. Our clients average 99214 utilization aligned to specialty benchmarks (35 to 50 percent in primary care, 60 to 70 percent in complex specialties) with audit findings under 1 percent. We monitor commercial payer downcoding patterns by client and surface trends within 30 days. Practical math: a primary care practice billing 1,000 established visits per month with current 99214 utilization at 25 percent and accurate utilization at 40 percent recovers roughly 6,000 dollars per month. That recovery covers our entire 2.49 percent service fee multiple times over. Use the CPT lookup tool to verify 2026 payment for any E/M code by state. If you run a practice under 10 providers, our medical billing for small practices service is built around exactly this kind of E/M revenue capture.