Healthcare Glossary→E&M Coding
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E&M Coding: Evaluation and Management

Evaluation and Management (E&M) codes define the level of physician visit service and determine reimbursement — with the 2021 CMS guideline revision eliminating history and physical exam requirements in favour of Medical Decision Making or total time.

The 2021 E&M Guideline Changes

Effective January 1, 2021, the AMA and CMS overhauled outpatient E&M coding. The previous system required documentation of history, physical examination, and medical decision making (or time). The revised system for office/outpatient visits (99202–99215) bases the code level solely on either Medical Decision Making (MDM) or total time on the date of service — whichever supports the higher level. History and physical exam documentation is still clinically appropriate but is no longer required for code selection.

Medical Decision Making Levels

  • Straightforward (99202/99212): Minimal problems (e.g., acute uncomplicated illness), minimal data review, minimal risk. Established ~$45 Medicare.
  • Low (99203/99213): Low complexity problems, limited data (review of prior results, order of tests), low risk (OTC medications). Established ~$78 Medicare.
  • Moderate (99204/99214): Moderate complexity (chronic illness with exacerbation, 2+ stable chronic conditions), moderate data (independent interpretation of test, discussion with external provider), moderate risk (prescription management). Established ~$111 Medicare.
  • High (99205/99215): High complexity (chronic illness with severe exacerbation, threat to life or bodily function), extensive data, high risk (drug therapy with intensive monitoring, surgery). Established ~$147 Medicare.

Time-Based Billing

If using total time for code selection, the threshold is: 99212 ≥10 min; 99213 ≥20 min; 99214 ≥30 min; 99215 ≥40 min; 99205 ≥60 min. Time includes all physician time on date of service related to the encounter (reviewing records, documenting, ordering, communicating) — not just face-to-face time.

E&M Coding Distribution Analytics

Analysing a practice's E&M code distribution reveals coding patterns against specialty benchmarks. A primary care practice where 70% of established patient visits are 99213 may be under-coding if the patient population includes significant chronic disease management. The revenue difference between 99213 and 99214 is approximately $33/encounter. A physician seeing 20 patients/day, 220 days/year, who shifts 30% of encounters from 99213 to 99214 adds approximately $43,000/year in revenue.