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E/M Changes in 2026: What You Need to Know

Garvit Chouhan

Head of RCM Delivery, Neolytix | MBA (International Business) · Six Sigma Black Belt (NASBA-US) · LSSGB (KPMG India) | 9+ Years in US Healthcare RCM

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E/M changes in 2026, revised by AMA and CMS, allow providers to select codes across seven service settings using medical decision-making or total time spent.

Hospital same-day admission and discharge stays over 8 hours bill under CPT 99234–99236; stays under 8 hours use CPT 99221–99223 instead.

MDM code selection is valid when only two of three elements are met — problem complexity, data reviewed, and risk of complications or morbidity.

For split/shared visits, CMS assigns the substantive portion to the practitioner who spent more than half of the total time or performed a substantive part of the medical decision making, and documentation must identify both practitioners.

Providers must link ICD-10-CM diagnosis codes, document SDOH categories Z55–Z65, and code to the highest specificity level on every claim.

In 2026, E/M code selection continues to follow the framework the American Medical Association (AMA) introduced for office visits in 2021 and extended to other settings in 2023. The Centers for Medicare & Medicaid Services (CMS) also adopted this framework. Providers select the code level using either medical decision making (MDM) or total time on the date of the encounter.

This expansion included continued outpatient E/M CPT 99202-99215 office visits code selection based on Medical Decision-making (MDM) or time. Including:

Hospital Inpatient and Observation Care Services 99221-99233,

Inpatient and Outpatient Consultations 99242-99255,

Emergency Department 99281-99285,

Initial and Subsequent Nursing Facility Care,

New and Established Home or Residence Services follow the same guidelines, allowing providers to select their code level based on MDM or time.

The core rules are unchanged in 2026. What did change are Medicare payment policies, covered below.

What Changed for E/M Coding in 2026?

The CPT MDM and time rules carried over from 2024 without structural changes. The 2026 updates come from the CY 2026 Medicare Physician Fee Schedule final rule:

Conversion factor: $33.40 for non-qualifying APM participants and $33.57 for qualifying APM participants.
Efficiency adjustment: CMS applied a 2.5% reduction to work RVUs for non-time-based services. E/M services, care management, behavioral health and telehealth-list services are exempt.
Frequency limits removed: CMS permanently removed frequency limitations on subsequent inpatient and subsequent nursing facility visits furnished via telehealth.
G2211: Use of the complexity add-on code G2211 was extended to home and residence visits.

G2211 and the home-visit extension come from AAFP. Everything else comes from the CMS fact sheet.

Since 2024, time for office visits must be met or exceeded instead of falling within a range.

Example: Dr. Jones spends 36 minutes with an established patient. Under the pre-2024 rules, this fell within the 30 to 39 minute range for 99214. Under the 2024 and 2026 rules, 99214 requires at least 30 minutes, so 36 minutes still supports 99214. At 40 minutes or more, 99215 would apply.

For hospital inpatient or observation care where the patient is admitted and discharged on the same date, code selection depends on length of stay. These codes are reported by the physician or qualified healthcare professional who performs both the initial and discharge services.

Example: In 2026, Dr. X admits Mrs. S to observation at 2am on a Thursday for a severe headache. Later, in the day Dr. X sees Mrs. S who is stable and feeling a lot better following IV fluids and medication. Mrs. S was discharged at 12:00pm Dr. X will bill E/M codes 99234-99236 based on MDM or time.

If Mrs. S was discharged less than 8 hours her visit would be billed by Dr. X with E/M codes 99221-99223.

2026 MDM Table: The Four Levels of Medical Decision Making

MDM level is set by meeting or exceeding 2 of 3 elements: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of patient management.

Straightforward MDM (99202 new, 99212 established)

Problems: 1 self-limited or minor problem
Data: minimal or none
Risk: minimal

Low MDM (99203 new, 99213 established)

Problems: 2 or more self-limited or minor problems, 1 stable chronic illness, or 1 acute uncomplicated illness or injury
Data: limited
Risk: low

Moderate MDM (99204 new, 99214 established)

Problems: 1 or more chronic illnesses with exacerbation or progression, 2 or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis, or an acute illness with systemic symptoms
Data: moderate
Risk: moderate, such as prescription drug management

High MDM (99205 new, 99215 established)

Problems: 1 or more chronic illnesses with severe exacerbation, or an acute or chronic illness posing a threat to life or bodily function
Data: extensive
Risk: high, such as a decision regarding hospitalizatio

2026 E/M Time Thresholds for Office Visits

Time must be met or exceeded on the date of the encounter.

New patients: 99202: 15 minutes · 99203: 30 minutes · 99204: 45 minutes · 99205: 60 minutes
Established patients: 99212: 10 minutes · 99213: 20 minutes · 99214: 30 minutes · 99215: 40 minutes

Code 99211 has no MDM or time requirement. Emergency department codes 99281-99285 are selected by MDM only

MDM Levels Across Care Settings

Straightforward or low: initial hospital 99221, subsequent hospital 99231
Moderate: initial hospital 99222, subsequent hospital 99232
High: initial hospital 99223, subsequent hospital 99233
Emergency department: straightforward 99282, low 99283, moderate 99284, high 99285

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Things to Remember in 2026

1. Elimination of History and/or Examination in Code Selection

Elimination of History and/or Examination in Code Selection

Following the E/M changes in 2023, determining the extent of the history and physical examination is no longer required. It will be the provider’s responsibility to perform and document the history and physical examination that they deem medically necessary for that patient at the time of the visit.

2. Medical Decision Making vs. Total Time Spent

Physicians and other qualified health professionals are now able to assign an appropriate level of E/M service based on one of the following criteria:

The level of medical decision-making (MDM) is defined in the 2026 medical decision-making table.
The total time for E/M services performed on the date of the encounter.

Providers must choose MDM or time but never both. Which method to use will be at the discretion of the provider.

Let us review each section of the medical decision-making table. According to the initial E/M changes that took place in 2021, medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.

Medical decision making in the seven services code sets listed above defined by three elements:

The number and complexity of the problem or problems that the provider addresses during the E/M encounter.
The amount and/or complexity of the data to be reviewed and analyzed, following the guidelines in the AMA MDM table.
The risk of complications, morbidity, and/or mortality of patient management decisions made during the visit, as outlined in the 2026 MDM guidelines. These might be associated with the patient’s problems, the diagnostic procedures, or the treatment.

Previous E/M guidelines required providers to document MDM as either straightforward, low complexity, moderate complexity, or high complexity. While these four types of medical decision-making categories have remained, the MDM table of risk has been revised to focus on activities that affect management of a patient’s condition. Note that only two of the three MDM elements are required for the overall MDM level.

3. Number & Complexity of Problems Addressed During the Encounter

A problem also known as our diagnosis addressed or managed when its evaluated/treated at the encounter by the physician or other qualified healthcare professional who is reporting the service.

The provider must demonstrate that the issue has been evaluated to receive credit for the problem or treatment. Be aware that a note in the patient’s medical record, explaining that another professional is managing the problem without further documented assessment or care coordination, does not qualify as being “addressed” or “managed” by the physician or other qualified healthcare professional reporting the services.

Key terms to consider:

Self-limited or minor problems

Stable chronic

Acute, uncomplicated illness or injury

Undiagnosed new problem with uncertain prognosis

Chronic illnesses with severe exacerbation, progression, or side effects of treatment

4. Amount and/or Complexity of Data to Be Reviewed and Analyzed

This data includes medical records, tests, and/or other information that should be obtained, ordered, reviewed, and analyzed for the patient encounter. These cannot be the provider’s own notes. The provider must review and analyze his or her notes without simply copying/pasting them into the medical record.

Data is divided into three categories according to the new E/M guidelines for 2026:

Tests, documents, orders, or independent historian(s). Each distinct test, order, or document is counted towards a threshold number.
The independent interpretations of tests.
Discussion of management and/or test interpretations with an external physician or other qualified healthcare professional or appropriate source.

Data includes information obtained from multiple sources or interprofessional communication that is not separately reported. For example, if the provider documents an EKG that was performed in the office and subsequently billed for, that information cannot be used in this section.

On the other hand, if a provider receives an MRI report for a diagnostic center, and then reviews images/interprets that report during or just before the patient encounter, then the provider will receive credit only if images are reviewed and the provider states they did their own interpretation. If the provider orders the test and only reviews the report on a second visit, he/she is not able to count in data. As the order and read was counted in the first visit.

5. Risk of Complications, Morbidity, and/or Mortality

This comprises the risk of complications, morbidity, and/or mortality of patient management decisions that are made at the visit AND associated with the patient’s problem(s), diagnostic procedure(s), and/or treatment(s).

This includes management options selected, as well as options considered but not selected, after shared medical decision-making with the patient and/or family.

The 2026 AMA E/M guidelines provide the following examples as a reference. According to the AMA, “a decision about hospitalization or escalation of hospital-level care includes consideration of alternative levels of care.”

Examples may include:

“A psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.”

6. Risks Associated with “Social Determinants of Health”

“Social determinants of health (SDOH) are economic and social conditions that influence health. SDOH is something you may be familiar with from ICD-10-CM coding, specifically categories Z55.- to Z65.-, Persons with potential health hazards related to socioeconomic and psychosocial circumstances.”

Finally, be aware that AMA has provided a table for CPT E/M office revisions. Fully updated for E/M changes in 2026, the Level of Medical Decision-making (MDM) chart will help you in assigning the proper CPT code. For a quick reference, see the 2026 MDM levels and time thresholds earlier in this article. The full criteria are in the AMA’s official MDM grid.

7. Documentation Considerations

The assessment of the level of risk is determined by the nature of the event currently under consideration.

For instance, a stable, chronic illness is when a patient’s treatment goals determine whether the illness is stable. A patient who has not achieved their treatment goal is not considered stable, even if their condition has not changed and there is no immediate threat to life or to function.

Definitions of risk are based upon the ordinary behavior and thought processes of a physician or another qualified healthcare professional in that same specialty. For the purposes of medical decision-making, the level is based on consequences of the problem(s) addressed during the encounter when appropriately treated. Risk further includes medical decision-making relating to the need to initiate or forego further testing, treatment, or hospitalization. Be aware that medical necessity must still be evident and demonstrated in the documentation.

8. Total Time Spent

The second option for selecting the appropriate CPT codes is based on the total time of the encounter on the date of the encounter for the level of services listed above except the Emergency Room.

For coding purposes, time for these services is the total spent on the date of the encounter, face‐to‐face and non-face‐to‐face with the patient. Time must be documented in the medical note for each activity to account for what was done. Total time will include all the time personally spent by the physician and/or other qualified healthcare professional in the care of the patient on the date of the encounter.

If time is used to specify the appropriate level for E/M services codes, be aware that time is defined by the service descriptors.

Timed activities that may be performed include:

Preparing to see the patient (e.g., review of tests)

Obtaining and/or reviewing separately obtained history.

Performing a medically appropriate examination and/or evaluation

Counseling and educating the patient/family/caregiver.

Ordering medications, tests, or procedures

Referring and communicating with other health care professionals (when not separately reported)

Documenting clinical information in the electronic or other health record

Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.

Care coordination (not separately reported)

9. Shared/Split Visits

Split (or shared) E/M visits refer to visits provided by physicians and in part by other nonphysician practitioners in hospitals and different institutional settings, including skilled nursing facilities (SNF). Split (or shared) visits are E/M visits performed jointly by a physician and a nonphysician practitioner (NPP) in a facility setting, such as a hospital or skilled nursing facility. For Medicare, the “substantive portion” is either more than half of the total time spent by both practitioners or a substantive part of the medical decision making. The practitioner who performs the substantive portion bills the visit, and modifier FS identifies the claim as split/shared.

Additionally, CMS requires the documentation to identify the two individuals who performed the service, and the billing professional sign and date the record.

10. Split Shared in Layman Terms

Layman terms: CMS will allow the substantive portion to be determined based on the practitioner who spent more than 50% of the time or the practitioner who performs and approves the medical decision-making (MDM). When time is used, time spent with the patient jointly by both practitioners can only be counted once.

Consider the following examples:

Example: If the NPP first spent 7 minutes with the patient and the physician then spent another 10 minutes, their individual time spent would be summed to equal a total time of 17 minutes. The physician would bill for this visit since they spent more than half of the total time (10 of 17 total minutes). If, in the same situation, the physician and NPP met together for eight additional minutes (beyond the 17 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit. The total time would be 25 minutes, and the physician would bill for the visit since they spent more than half of the total time (18 of 25 total minutes).

Split/shared billing applies only in facility settings. In the office setting, services performed by an NPP follow Medicare’s incident-to rules instead. For the calendar year 2026, if you’re not using time to determine billing, you should bill CPT codes 99231–99233 based on the key component level. This means the billing practitioner must perform and document the medical decision-making (MDM).

For further clarification, providers can refer to the EM coding guidelines 2026 PDF and use the E&M coding cheat sheet 2026 for quick references. The Emergency Department Coding Guidelines 2026 and ER CPT codes 2026 provide specific guidance for emergency settings. For time-based coding, the time-based E/M coding 2026 and E/M time-based billing 2026 guidelines will be essential.

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What's Proposed for E/M in 2027

CMS published the CY 2027 Physician Fee Schedule proposed rule on July 16, 2026. According to the AMA, it proposes a 50% payment reduction when a separately identifiable office or outpatient E/M visit reported with modifier 25 is billed on the same day as most procedures. The AMA also reports a proposed 1.68% conversion factor decrease for non-APM participants. These are proposals, not final policy. CMS typically releases the final rule in early November.

Conclusion

As you can see, the E/M changes in 2026 for the first seven sections of E/M Services require careful training for all those who participate in claim submission, including providers, coders, and EMR vendors.

These E/M changes are chiefly intended to streamline documentation. The goal is to reduce administrative burden and increase the amount of time physicians can spend with patients.

Keep in mind that medical coding must, as much as possible, accurately reflect what occurred during the encounter and substantiate medical necessity. Providers should continue to link ICD-10-CM diagnosis codes and assign any social determinants of health that may affect the care of the patient. Always strive to document diagnosis codes to the highest degree of specificity.

Would you like some assistance with your medical billing and coding? Neolytix is more than happy to assist your practice with Medical Billing Services, Medical Credentialing Solutions, and much more.

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Sources

CMS Medicare Learning Network — https://www.cms.gov/training-education/medicare-learning-network-mln
AMA E/M Resources — https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
CMS Coding & Billing — https://www.cms.gov/medicare/coding-billing
CMS: CY 2026 Medicare Physician Fee Schedule Final Rule fact sheet
AMA: CPT E/M revised MDM grid
AMA: 2027 proposed Medicare fee schedule, what physicians need to know
Federal Register: CY 2027 PFS proposed rule (July 16, 2026)
AAFP: 2026 Medicare Payment and CPT Coding Update

Frequently Asked Questions

What is the MDM table for 2026?

The MDM table defines four levels of medical decision making: straightforward, low, moderate and high. Each level requires meeting 2 of 3 elements: problems addressed, data reviewed and analyzed, and risk of patient management. It maps to office codes 99202-99205 and 99212-99215.

Did E/M coding guidelines change in 2026?

The CPT MDM and time framework carried over from 2024. For Medicare, 2026 brought a $33.40 conversion factor for non-APM participants, a 2.5% efficiency adjustment that exempts E/M services, and permanent removal of telehealth frequency limits on subsequent inpatient and nursing facility visits.

What are the 2026 time thresholds for office visits?

New patients: 99202 is 15 minutes, 99203 is 30, 99204 is 45 and 99205 is 60. Established patients: 99212 is 10, 99213 is 20, 99214 is 30 and 99215 is 40. Time must be met or exceeded.

Can I use both MDM and time to select an E/M level?

No. Choose either MDM or total time for each encounter, whichever better supports the level. You can’t combine elements of both.

Can emergency department visits be coded by time?

No. ED codes 99281-99285 are selected on MDM only.

Reviewed by Ritu Bhatnagar

Ritu Kalsi Bhatnagar — President & COO, Neolytix | 23+ Years in Healthcare RCM & Compliance

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