What changed in E/M coding in 2021 and 2023?

The 2021 changes for office/outpatient E/M codes (99202–99215) eliminated the history and exam as elements of code selection — only MDM or time is used. The 2023 changes extended this approach to other E/M categories like hospital inpatient, observation, ED, nursing facility, and home visits. The result is simpler coding across the board: pick the E/M level based on the medical decision making or the total time on the date of the encounter.

MDM-based vs time-based — which should I use?

Use whichever supports the higher code level for the encounter. If the MDM is moderate and the time is 22 minutes, MDM-based coding might give you a 99214 (moderate), while time-based would limit you to 99213 (20–29 minutes). Conversely, if the MDM is low but you spent 35 minutes on counseling, time-based coding would support a 99214. Document both the MDM and the time — then you can justify the higher level.

What are the time thresholds for 2026?

For office/outpatient visits: New patient — 15 min (99202), 30 min (99203), 45 min (99204), 60 min (99205). Established patient — 10 min (99212), 20 min (99213), 30 min (99214), 40 min (99215). For ED visits: 99281 (no threshold), 99282 (20 min), 99283 (30 min), 99284 (40 min), 99285 (55 min). These reflect the total time on the date of the encounter, not just face-to-face time.

How do I explain the difference between 99213 and 99214 to a provider?

Show them the payment difference. 99213 pays $92.13. 99214 pays $131.98. That's $39.85 more for adding one additional element — a lab order, a review of old records, or documentation of moderate risk. I have found that showing providers the dollar amount makes the concept concrete. It is not about 'upcoding.' It is about documenting what you did and billing what you documented.

Can I use the extension to look up E/M payment data in real time?

Yes. Open the side panel and search any E/M code — 99213, 99214, 99284, 99204. The search result shows the code description, Medicare payment amount, and billable status. Hover over a detected E/M code in your superbill or clinical note and the tooltip shows the same data. Use it to compare levels before you submit the claim.

Guide · 10 min read

E/M Coding 2026:
How to Level 99202–99215 Correctly With Payment Data

Evaluation and management coding is the most frequently audited area in medical billing. Here is how MDM-based and time-based leveling work in 2026 — with real Medicare payment data for every level.

Browse E/M Code Data

The Short Version

E/M coding in 2026 is simpler than it was before the 2021/2023 guideline changes. For office and outpatient visits (99202–99215), you select the code level based on either medical decision making (MDM) — across four levels from straightforward to high — or total time on the date of the encounter. History and exam elements no longer factor into code selection.

This guide walks through each MDM level with real examples, the time thresholds for new and established patients, and the Medicare payment data that makes level selection an economic decision as much as a clinical one. Use the icd10free extension to look up payment data while you code — no tab switching, no CMS PDF hunting.

MDM Levels

Coding Methods (MDM / Time)

$39.85

Gap Between 99213 & 99214

100%

Free Payment Data Lookup

The #1 Audit Target

I have sat through enough RAC audits to know this: E/M coding is the first thing auditors look at. It is the highest-volume code family in medical billing, the most subjective to level, and the easiest to get wrong when the documentation is incomplete. Every Medicare audit I have reviewed starts the same way — pull the E/M codes, check the MDM, compare the levels.

The 2021 and 2023 guideline changes were supposed to make E/M coding easier. And they did — but only if you understand how MDM works in practice. The old system required counting history elements and exam bullet points. The new system asks a simpler question: how complex was the medical decision making? But simplicity does not mean easy. The problem is that providers and coders have to retrain themselves to think in terms of MDM pillars rather than bullet points.

This is where payment data becomes a practical tool. When you see that 99213 pays $92.13 and 99214 pays $131.98, the conversation with a provider shifts from 'document more MDM elements' to 'document what you did so the level matches the work.' The dollar amount makes the guideline real.

How E/M Code Leveling Works in 2026

Determine the Type of Encounter

Is this a new patient, an established patient, or another type of visit (consultation, emergency department, nursing facility)? Each type has its own code range — 99202–99205 for new patients, 99211–99215 for established. The type determines which MDM table to use.

Assess Medical Decision Making (MDM)

MDM is evaluated across three pillars: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the level of risk. Each pillar contributes to one of four levels: straightforward, low, moderate, or high. The highest level across all three pillars determines the MDM level.

Check Time-Based Coding (if applicable)

If counseling and coordination of care dominated the encounter, you can code based on total time on the date of the encounter. The 2021 and 2023 changes simplified this: for 99212–99215, use the total time thresholds (10, 20, 30, 40 minutes for established; 15, 30, 45, 60 for new). No more 50% counseling rule for most visits.

Verify With Payment Data in the Side Panel

Open the icd10free side panel and search the E/M code you're considering. Check the Medicare payment, compare levels, and see the full code descriptor. The payment difference between 99213 and 99214 is $39.85 — a gap that adds up fast across 1,000 annual visits.

The Four MDM Levels

Level	Problems	Data	Risk	New Pt Code	Est. Pt Code
Straightforward	Self-limited or minor (1)	Minimal or none	Low	99202	99212
Low	Low severity (2+ minor, 1 stable chronic)	Limited (lab/vital order, review of old records)	Low	99203	99213
Moderate	Moderate severity (1+ chronic with exacerbation, 1+ injury)	Moderate (2+ tests, independent historian, discussion with another provider)	Moderate (prescription drug, minor surgery)	99204	99214
High	High severity (1+ chronic with severe exacerbation, acute threat to life)	Extensive (3+ tests, independent historian, discussion with another provider)	High (elective major surgery, drug requiring monitoring)	99205	99215

Source: CMS 2026 Documentation Guidelines for E/M Services. Medicare payment data available via the icd10free extension side panel.

Real-World E/M Coding Scenarios

New Patient: 99202 vs 99203

A 45-year-old new patient presents with low back pain for two weeks. The history is straightforward, the exam is focused on the lumbar spine, and no diagnostic tests are ordered. The physician documents the diagnosis and recommends conservative care. MDM: The problem is self-limited or minor (straightforward). Data reviewed is minimal. Risk is low. This is a 99202 (straightforward MDM). Payment: $77.37. If the physician ordered an X-ray, reviewed prior imaging, and initiated a treatment plan with prescription NSAIDs, the MDM would rise to low — making it a 99203 ($108.78).

Established Patient: 99213 vs 99214

A 68-year-old established patient with diabetes and hypertension returns for follow-up. Blood pressure is elevated, and the A1c is 7.8%. The physician adjusts medications and orders lab work. MDM: Two or more chronic conditions with exacerbation (low to moderate). Data includes lab orders (moderate for Category 1 decision). Risk is low. This is a borderline 99213/99214 depending on physician documentation. If the physician expressly documents medical decision making complexity, the 99214 payment ($131.98) is $39.85 more than 99213 ($92.13). The difference across 500 Medicare visits is nearly $20,000 — a non-trivial revenue impact.

ED Visit: 99283 vs 99284

A patient presents to the ED with chest pain, shortness of breath, and an abnormal EKG. The physician orders cardiac enzymes, a chest X-ray, and a cardiology consult. The patient is admitted to observation. MDM: The problem is high severity (chest pain with abnormal EKG). Data includes multiple diagnostic tests and a consult. Risk is high. This is a 99284 (moderate MDM for ED visits). If the physician had only ordered an EKG and discharged the patient with antacids, it would be a 99283. The payment difference: 99284 ($177.23) vs 99283 ($126.73) — a $50.50 gap for the same diagnosis with different decision-making intensity.

Tips from the Trenches

Three things I wish every coder and provider understood about E/M leveling.

Document the MDM, Not Just the Diagnosis

The single biggest reason E/M audits go against the provider is that the medical decision making is not documented even though it was done. The physician thought through the differential, reviewed outside records, considered the risks — but didn't write it down. If it is not in the note, it was not done. I tell every provider I work with: your note should explicitly state the complexity of the problem, the data you reviewed, and the risk you considered. Use words like 'I reviewed the patient's prior CT scan which showed...' rather than 'CT ordered.'

Undercoding Is Leaving Thousands on the Table

I have reviewed hundreds of E/M audits, and undercoding is more common than overcoding. Providers consistently document at a 99213 level when the actual MDM supports a 99214. The gap is $39.85 per visit. For a practice doing 2,000 established patient visits per year, that is nearly $80,000 in forgone revenue. Use the extension payment data to check: if you're consistently billing 99213 and your MDM description sounds like moderate, run a comparison search and let the data confirm what you should be billing.

Bookmark E/M Code Levels for Quick Reference

The E/M code levels are easy to memorize with daily use, but the payment amounts change annually. Bookmark your most-used E/M codes — 99203, 99213, 99214, 99284 — in a folder called 'E/M — Frequent.' Each year when the Medicare fee schedule updates, open your bookmarks and see the new payment amounts instantly. No spreadsheet, no CMS PDF download, no math.

Frequently Asked Questions

Questions I hear from coders navigating the 2021/2023 E/M guideline changes.

Ready to Look Up E/M Payment Data?

Search any E/M code in the extension side panel or on icd10free.com to see the description, payment amount, and billable status instantly.

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E/M Coding 2026:How to Level 99202–99215 Correctly With Payment Data