Starting in January 2026, the American Medical Association (AMA), in conjunction with the Centers for Medicare & Medicaid Services (CMS), expanded and revised the 2026 Evaluation and Management (E/M or EM codes 2026) Coding guidelines.
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.
Many of these changes remain in 2026.
What do physicians need to know about E/M changes in 2024?
Primarily, physicians should remember that they are following one set of guidelines for multiple places of service. In this article, we will explore 2026 e/m changes providers should be aware of, which include:
- Office Outpatient time changes for new and established patients
- Hospital Inpatient or Observation Care Services, (including Admission and Discharge Same Services)
- Split Shared Visit guidelines.
As detailed by the AMA, there is one substantial change in 2024 which is time is now stated as “must be met or exceeded” versus a start and stop time for E/M codes in the categories listed above.
Example 2026: Dr. Jones saw an established patient in the office and would like to select an E/M code based on spending 36 minutes of time with the patient. For this visit we would select level 4-99214 based on 30-39 minutes of total time spent on the date of the encounter.
In 2026, Dr. Jones sees the same patient in the office and would like to select an E/M code based on spending 30 minutes of time with the patient. For this visit we would select a level 4-99214 based on 30 minutes must be met or exceeded.
In 2026, the AMA will guide us in selecting the E/M codes based on the length of stay for hospital inpatient or observation care services (including admission and discharge). The following grid is to help providers, medical billers, and medical coders report hospital inpatient or observation care services provided to patients admitted and discharged on the same service date when the stay is more than eight hours. These services are only used by the physician or qualified healthcare professional team performing 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.
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 (e/m mdm table 2026)
- 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 medical decision making table 2024.
- 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.
Please, refer to the AMA Code, definitions, and Guideline changes document, pgs. 8-9 in the 2026 Current Professional Terminology (CPT) book.
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. Find the chart here.
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)
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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). For CY 2026, the revision for the definition of “substantive portion” of a split (or shared) visit is to include the revisions to the Current Procedural Terminology (CPT) guidelines, such that for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical substantive portion of a split (or shared) visit.
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.
Provider types include MD, DO, PA and NP when patients are seen in place of service 19 off-campus outpatient hospital or 22 on campus outpatient hospitals. For outpatient office visits, only incident-to billing is allowed.
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).
Additionally, for MDM billing 2024 protocol, in order to bill as a split or shared subsequent hospital service, the billing practitioner reports CPT code 99231 if basing the coding on time. 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.
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.
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