The AMA rewrote E/M coding rules in 2023 — scrapping the old key-element system that practitioners used for decades. Three years later, payers are still running audits based on the old criteria, and a lot of practices are still documenting like it's 2022. That mismatch is expensive.
If your E/M billing hasn't been reviewed since the change, there's a real chance you're either under-coding — leaving money on the table — or over-coding in ways that look suspicious to a payer auditor. Neither is good. Here's what the rules actually say in 2026 and what your documentation needs to show.
Under the current AMA guidelines, you pick one of two methods to determine your E/M level for office and outpatient visits — Medical Decision Making (MDM) or total time. You don't use key elements (history, exam, medical decision making scored separately) anymore. That system is gone for office visits.
Most practices default to MDM because it maps to what physicians naturally document. Time-based billing makes more sense for visits that run longer than usual or involve significant care coordination outside the face-to-face encounter.
MDM has three columns. You need to meet or exceed two of the three to assign a level.
| MDM Level | Problems | Data Reviewed | Risk |
|---|---|---|---|
| 99202 / 99212 | Self-limited / minor | Minimal or none | Minimal |
| 99203 / 99213 | Low complexity (stable chronic) | Limited | Low |
| 99204 / 99214 | Moderate complexity | Moderate | Moderate |
| 99205 / 99215 | High complexity | Extensive | High |
This is where most documentation falls short. A stable chronic condition — say, well-controlled Type 2 diabetes with no new symptoms — counts as one low-complexity problem. Two or more stable chronic conditions at the same visit push you to moderate complexity. An undiagnosed new problem with uncertain prognosis hits high complexity on its own.
Your notes need to specifically address what's going on with each problem — not just list diagnoses. "HTN - stable, continue lisinopril" documents a problem. "HTN" alone doesn't.
This one trips people up because there are sub-elements. For moderate MDM, you need to meet one of three data categories:
Ordering a lab and just noting "CBC ordered" doesn't get you the data credit. You need to document your interpretation — "CBC shows mild anemia, likely iron deficiency given diet history, will start supplementation and recheck in 6 weeks."
Prescription drug management automatically qualifies as moderate risk. That's a big one. If you're prescribing or managing a prescription at the visit, you're already at moderate risk — which means you only need one more column at moderate to justify a 99214.
High risk includes things like decisions about hospitalization, drug therapy requiring intensive monitoring, or diagnosis or treatment significantly limited by social determinants of health.
Total time now includes time spent on the day of the encounter — not just face-to-face time. That means pre-charting, reviewing records before the patient arrives, care coordination calls you make on the day of the visit, and documentation done the same day all count.
| Code | New Patient (min) | Established Patient (min) |
|---|---|---|
| 99202 / 99212 | 15–29 | 10–19 |
| 99203 / 99213 | 30–44 | 20–29 |
| 99204 / 99214 | 45–59 | 30–39 |
| 99205 / 99215 | 60–74 | 40–54 |
When you bill by time, document the total time and what you spent it on. "Total time: 45 minutes including pre-visit chart review (10 min), face-to-face visit (25 min), care coordination with specialist (10 min)" — that's what auditors want to see.
The biggest audit targets in 2026 are practices that switched to time-based billing but don't document the time breakdown — just a total number. And practices still using the old key-element documentation in their EHR templates without realizing the templates haven't been updated.
Many EHR systems shipped "2023 E/M compliant" templates that still prompt for Review of Systems and Past/Family/Social History as required fields. Those elements aren't required for E/M level selection anymore — but documenting them isn't wrong. The problem is when providers skip MDM documentation because they think the ROS fields are what's driving the level.
Telehealth office visits (99202–99215 with modifier 95 or GT) follow the same MDM and time rules as in-person visits. The documentation requirements are identical. Place of service code 02 (telehealth) or 10 (patient home) applies depending on where the patient is.
Hospital observation and inpatient codes (99221–99223, 99231–99233) also now use MDM or time. Same structure. The nuance here is that inpatient time can include time spent on the unit reviewing the chart, talking with nursing staff, and writing notes — not just bedside time.
Initial hospital care still requires a comprehensive history and exam, but the level is determined by MDM or time, not by whether you documented 10 systems or 8 systems in your review.
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