E&M Coding Changes in 2026

If you’re tired of counting bullet points to assign an E&M code to an outpatient, I have some good news for you. According to the new guidelines by the American Medical Association (AMA), Evaluation and Management (E&M) coding is going to be much simpler than before. As of now, all changes are for outpatient codes. However, changes in other E&M Coding are expected to follow. With such a drastic change in E&M coding, you should also question if your medical software providers, like EHR software, are ready for the change. Starting Jan. 1, practitioners will select their E&M codes based on their total time spent in care for the patient or the medical decision-making (MDM) involved in patient care, whichever is most beneficial. Also, Medicare reimbursements will modestly increase for each level. If you think these are only minor changes and wouldn’t affect your medical practice, you couldn’t be more wrong. The reason is that without accurate Coding for outpatients, you could have increased denied claims, reduced reimbursements, and so on. In this blog, we’ll be discussing the following:

Before we move on to the changes in E&M coding, let’s talk about why these changes were necessary in the first place.

Was There A Need For Change?

The E&M coding changes were designed with help from the Centers for Medicare and Medicaid Services (CMS) to:

  • Reduce the burden of administrative tasks on physicians
  • Change payments for E&M codes
  • Streamline documentation requirements

CMS’s initial proposal was to break down office visit E&M levels 2-5 to a single payment. While it would have provided a modest increase for level 2 and 3 E&M codes, it would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. Naturally, this proposal faced rejection from the physician communities. After that, the AMA worked with stakeholders and came up with a proposal that would decrease physician documentation requirements while also continuing to differentiate payment based on care complexity. Resultantly, with these changes, there will be modest payment increases for most office E&M codes beginning Jan. 1, which may benefit those who manage patients with complex conditions.

What Are The Fundamental Changes In E&M Coding?

Although there are numerous changes made to the E&M codes, there are a few that stand out. Here are some of the more prominent ones:

  • Deleting level 1 new patient visit (99201)
  • Prolonged services (15 minutes) can be reported under 99215 and 99205
  • No time reference in code 99211
  • Established new codes 99212-99215

You can read up on all of the changes made on the official AMA website. Also, you might need to reorganize your medical practice to fit the requirements of E&M changes.

Code-level to be determined by medical decision-making or time. Elimination of history and physical exam as elements in code selection.

Though performing a physical exam and recording patient history are clinically necessary and contribute to medical decision-making and time, these elements will not factor into code selection. Instead, the code level will now be determined solely by medical decision-making or time.

Choosing Between Medical Decision Making (MDM) And Total Time In The E&M Documentations

The MDM still includes only three components: the complexity of the problem, risk, and data. However, extensive edits have been made to the way these elements are defined and tallied. Redefinition of the concept of time meaning minimum time, not the typical time or “face-to-face” time. Minimum time represents the total time a physician/qualified health professional will spend on the date of service. With this change, physicians will now be reimbursed for non-face-to-face services such as care coordination essential for patient care.

Tweaks In The Selection Criteria For MDM

One of the significant changes made in the criteria for MDM is specificity. Terms that were vague and possibly confusing have been replaced with specific terms and phrases. For instance, the word ‘mild’ was replaced with ‘acute or chronic.' Secondly, previously undefined terms, such as 'Independent Historian’, were also defined and specified. CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) on Jan. 1, which can assess any additional costs that may occur when dealing with complex patients.

Are E&M Coding Changes For Everyone?

Any changes in the E&M office/outpatient CPT codes for either new or existing patients apply to Medicare, Medicaid, Medicare Advantage Plans, and commercial bodies. However, E&M of HCPCS codes are only applicable to Medicare, Medicaid, and Medicare Advantage Plans. Commercial payers are not required to accept HCPCS codes.

What Can You Do To Prepare For E&M Coding?

So there you have it, all of the changes that will be made to E&M Coding. However, you might be thinking, “How do I plan for these changes?” Here’s a list of precautions you can take to ensure you stay ahead of the curve.

  • Reach Out To Your EHR Vendor: discuss their plans for incorporating the changes. Mainly about how the EHR’s code calculator inculcates time and MDM. Would the EHR software be able to differentiate between the changed codes and others?
  • Reach Out To Your Medical Billing Partner: You may also contact your medical billing service provider to learn what they’re doing to facilitate the changes. Likely, some service providers would still prefer their selection criteria to be based on physical and historical factors.
  • Make Sure Your Staff Understands Medical Necessity: Even if you choose the total time in E&M coding documentation, make sure the time reported is realistic. Chances are, if a doctor reports 60 minutes for a patient with a concussion, they won’t be able to justify it.
  • Take A Glance At Your Current Documentation: Does your current documentation support total time as a measure in MDM? How aligned are you with the AMA’s new guidelines?

Conclusion – Are You Ready for E&M Coding Changes?

Numerous E&M codes for outpatients have been re-aligned to help remove some of the burdens on physicians. It also helps streamline lengthy documentation to help clear up your time. Although these changes can seem scary initially, they should be better once you get the hang of it. You have time to plan, prep, educate, and implement effectively, but as time is winding down, you better put pen to paper soon!