2026 E/M Coding Changes: What Changed, What Didn't, What to Watch

The major E/M reform happened in 2021 when CPT moved office visit coding from a 1995 or 1997 history, exam, and medical decision making framework to a 2021 medical decision making or total time framework. The 2021 framework remains the governing rule in 2026. Office visit E/M codes (99202 through 99215) are selected based on either medical decision making (MDM) level or total time on the date of encounter. The MDM path uses three elements. Number and complexity of problems addressed, amount and complexity of data reviewed and analyzed, and risk of complications and morbidity. Two of three elements at a given level determine the E/M code. The time path uses total time on the date of encounter including time before, during, and after the patient encounter. Time-based coding requires documentation of total time. The 2021 framework was the biggest E/M change in 25 years. The 2026 updates are refinements to that framework, not replacements.

The 2026 E/M updates are clarifications and specific code additions rather than framework changes. Prolonged service codes received CPT clarification. 99417 (prolonged office visit time, each 15 minutes beyond the highest level E/M time) remains the code for additional time on 99205 and 99215. The 2026 update clarified that 99417 is billed only after the highest level E/M time threshold is exceeded, and each 15 minute increment must be fully completed (not partial). For Medicare, G2212 replaces 99417 for Medicare patients. G2212 has the same time requirements but Medicare-specific payment policy. Split shared billing rules were clarified. In 2026, the CPT Editorial Panel added specific language to the E/M guidelines about how split shared visits between a physician and a qualified health care professional (NP, PA) are documented and billed. The substantive portion of the visit drives the billing provider. The substantive portion is defined as more than half of the total time or the substantive portion of MDM. MDM definitions were refined for specific elements. The 2026 update provided additional examples of what constitutes moderate complexity problems versus high complexity problems. The examples help with consistency across specialties. Interprofessional consultations (99446 through 99449 plus 99451, 99452) received clarifying language about when they can be billed along with E/M services.

Most of the 2021 framework remains unchanged in 2026. The MDM-based selection continues as the primary path for most E/M coding. The total time path remains available as an alternative. The code ranges for office visits (99202 through 99215) are the same. Hospital visit codes (99221 through 99239), observation codes (99217 through 99226 where applicable in the newer structure), and consultation codes (99242 through 99255 where used) operate under the 2023 updates that consolidated these categories. The 2026 update did not introduce new office visit E/M codes or retire existing ones. The MDM grid structure with three elements and two-of-three scoring continues to govern office visit MDM scoring. For practices operating correctly under the 2021 framework, 2026 updates are refinements rather than overhauls. Practices still operating under pre-2021 rules should update urgently.

The MDM grid that drives most office visit E/M selection has three columns. Number and complexity of problems addressed. 99212 requires minimal problems (self-limited or minor). 99213 requires low complexity (stable chronic, acute uncomplicated). 99214 requires moderate complexity (chronic with exacerbation, acute with systemic symptoms, undiagnosed new problem with uncertain prognosis). 99215 requires high complexity (chronic with severe exacerbation, acute with threat to life or bodily function). Amount and complexity of data reviewed and analyzed. 99212 requires minimal data. 99213 requires limited (review of external records, order of tests, discussion with patient or family). 99214 requires moderate (review of external records, order of tests, independent interpretation of test, discussion with external physician or another qualified HCP). 99215 requires extensive (all of moderate plus independent historian for moderate reliability issues, or independent interpretation of tests with complexity). Risk of complications and morbidity from patient management. 99212 requires minimal risk. 99213 requires low risk (no medications, or OTC medication recommendations). 99214 requires moderate risk (prescription medication management, minor surgery with identified risk, elective major surgery without identified risk, diagnostic or therapeutic decisions with moderate risk). 99215 requires high risk (drug therapy requiring intensive monitoring for toxicity, decision regarding elective major surgery with identified risk, decision regarding emergency major surgery, decision not to hospitalize patient with illness that poses threat to life or bodily function). Two of three elements at a given level determine the code.

Time-based E/M coding selects the code based on total time on the date of encounter. The 2026 time thresholds match the 2021 thresholds. 99202 requires 15 to 29 minutes. 99203 requires 30 to 44 minutes. 99204 requires 45 to 59 minutes. 99205 requires 60 to 74 minutes (with 99417 or G2212 for each additional 15 minutes beyond 74 minutes). 99212 requires 10 to 19 minutes. 99213 requires 20 to 29 minutes. 99214 requires 30 to 39 minutes. 99215 requires 40 to 54 minutes (with 99417 or G2212 for each additional 15 minutes beyond 54 minutes). Time includes all provider time on the date of encounter. Reviewing records before the visit, the face to face visit, charting and documentation, ordering tests, writing prescriptions, coordinating care with other providers, and any time spent on the patient's care on the same calendar day. Time does not include time spent by clinical staff on their own work, time spent teaching residents, or time spent on date other than the encounter date. Documentation must specify total time and some detail about how the time was used (e.g., 10 minutes reviewing records, 25 minutes with patient, 10 minutes on orders and documentation). Time-based coding is most advantageous when MDM-based scoring would yield a lower level than the time-based threshold. Examples. A new patient visit with moderate MDM that takes 50 minutes bills 99204 (moderate MDM) or 99204 (45 to 59 minutes time). Same code either way. A new patient visit with low MDM that takes 50 minutes bills 99203 on MDM or 99204 on time. Time-based yields the higher code.

Split shared visits involve a physician and a qualified health care professional both participating in a single E/M encounter. The 2026 update clarified the rules for how these are billed. The substantive portion drives the billing provider. The substantive portion is defined as more than half of the total time on the date of encounter or the substantive portion of medical decision making. If the physician provides more than half of the total time, the visit bills under the physician. If the NP or PA provides more than half of the total time, the visit bills under the NP or PA. If time is evenly split or not trackable, the substantive portion of MDM drives the billing provider. The substantive portion of MDM is defined as the portion that establishes the final diagnosis and treatment plan. Documentation must support which provider performed the substantive portion. Unsigned or unclear notes default to the lower-paying provider (typically the NP or PA rather than the physician). Medicare applies split shared billing rules differently from commercial payers. Medicare typically requires the physician to personally perform at least a substantive portion of the encounter to bill under the physician NPI. Commercial payers increasingly align with the CPT framework but payer specific rules still vary.

Prolonged service codes cover time beyond the highest level E/M threshold. 99417 applies to 99205 or 99215 extensions, each 15 minutes beyond the threshold. Medicare uses G2212 for the same purpose with Medicare-specific policy. The 2026 clarification. Each 15 minute increment must be fully completed. A 99205 encounter taking 87 minutes bills 99205 plus 99417 x 1 (one full 15 minute increment completed for minutes 75 through 89). An 89-minute encounter does not bill 99417 x 2 because the second 15 minute increment is not yet complete. Documentation must clearly establish total time. Prolonged service billing is frequently denied when documentation lacks specific time for the prolonged portion. The fix is documenting the total time in the encounter note and explicitly noting the prolonged service time. Example. Total time on the date of encounter was 87 minutes. This included 15 minutes of prolonged service beyond the 99205 time threshold of 74 minutes.

The most common E/M coding errors under the 2021 to 2026 framework. Undercoding by defaulting to lower levels to avoid audit risk. The framework allows higher level billing when documentation supports. Underdocumentation leads to undercoding. The fix is documentation that establishes the MDM or time elements for the level billed. Overcoding by selecting levels without supporting documentation. The 2-of-3 MDM rule and the time thresholds are clear. Levels billed without documentation support fail audit tests. Confusing time-based and MDM-based coding. Either path is valid independently. Using time-based when MDM-based yields a higher code undersells the encounter. Using MDM-based when time-based yields a higher code undersells differently. Many practices apply whichever path yields the higher code on the specific encounter. Missing prolonged service billing when applicable. Extensions to 99205 or 99215 billing are often missed because providers do not document time. Documentation discipline captures this revenue. Incorrect split shared billing under Medicare versus commercial rules. Medicare and CPT rules differ. Train providers and billers on the distinction.