CMS E/M Documentation Guidelines 2026: Complete Reference

Evaluation and Management (E/M) services represent the largest category of claims submitted to Medicare and commercial payers, and they are the most frequently audited. Since CMS overhauled the E/M documentation framework in 2021 — eliminating the requirement to document the history of present illness, review of systems, and physical exam for code level selection — the system has been built on two pillars: medical decision making (MDM) and total time. Understanding these pillars in detail is essential for every provider, coder, and compliance professional.

This guide provides a comprehensive, code-level reference for E/M documentation requirements as they stand in 2026, incorporating the 2021 framework, subsequent annual updates, and the specific coding rules that apply to office visits, hospital visits, observation care, critical care, prolonged services, and split/shared encounters.

The 2021 E/M Framework: Foundation

The 2021 E/M guidelines, developed jointly by the AMA CPT Editorial Panel and CMS, fundamentally restructured how outpatient E/M services (99202-99215) are coded. The key changes:

Eliminated mandatory documentation of history and exam for code level selection. History and physical exam are still clinically important and should be documented as medically appropriate, but they no longer determine the E/M level. A provider can perform and document a comprehensive history and exam and still bill a level 3 visit if the MDM supports level 3.

Made MDM the primary basis for code selection. The complexity of MDM determines the E/M level for outpatient visits. MDM is assessed across three elements, and the level is determined by the highest two of three elements met.

Established time as an alternative basis. Providers may alternatively select the E/M level based on total time spent on the encounter on the date of service (for outpatient visits) or on the floor or unit (for inpatient/observation visits). Time includes both face-to-face and non-face-to-face activities.

Eliminated the distinction between new and established patient E/M levels. New patient visits (99202-99205) and established patient visits (99212-99215) now use the same MDM and time criteria. The only difference is the minimum time thresholds and the fact that new patient visits are typically reimbursed at higher rates.

Medical Decision Making: The Three Elements

MDM is assessed across three elements. The E/M level is determined by the highest two of three elements. This "2 of 3" rule means that a provider does not need to meet the criteria for all three elements at a given level — meeting two is sufficient.

Element 1: Number and Complexity of Problems Addressed

This element evaluates the problems that the provider addresses during the encounter. "Addressed" means that the provider evaluates, manages, or provides treatment or diagnostic workup for the problem during the encounter. Problems that are present but not addressed do not count.

MDM Level	Problems Addressed
Straightforward	1 self-limited or minor problem (e.g., cold, insect bite, superficial wound)
Low	2 or more self-limited or minor problems; OR 1 stable chronic illness (e.g., well-controlled hypertension); OR 1 acute, uncomplicated illness or injury (e.g., cystitis, sprain)
Moderate	1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment; OR 2 or more stable chronic illnesses; OR 1 undiagnosed new problem with uncertain prognosis (e.g., lump in breast); OR 1 acute illness with systemic symptoms (e.g., pyelonephritis); OR 1 acute, complicated injury (e.g., head injury with brief loss of consciousness)
High	1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; OR 1 acute or chronic illness or injury that poses a threat to life or bodily function (e.g., acute MI, pulmonary embolism, psychiatric illness with suicidal ideation, severe respiratory distress)

Documentation requirement: The provider must document what problems were addressed during the encounter. Each problem should be identified by name or description, and the encounter note should indicate what was done for each problem (assessment, plan change, diagnostic workup, counseling).

Element 2: Amount and/or Complexity of Data to Be Reviewed and Analyzed

This element evaluates the data the provider reviews, orders, and analyzes in connection with the encounter. Data includes tests, imaging, records from external sources, and discussions with other providers.

MDM Level	Data Requirements
Straightforward	Minimal or no data to be reviewed
Low	Order or review of tests, documents, or independent historian; meets any 1 of: (a) Order or review of any unique test (lab, imaging, other); (b) Review of prior external note(s) or external physician summary; (c) Review of result(s) of each unique test; (d) Order of each unique test; (e) Assessment requiring independent historian
Moderate	Meets any 1 of 3 categories: Category 1 — Order, review, and independent interpretation of test(s) requiring an independent interpretation (e.g., provider reviews ECG tracing, not just a cardiologist's report); Category 2 — Discussion of management or test interpretation with external physician/QHP/appropriate source; Category 3 — Independent interpretation of a test performed by another provider (not separately reported)
High	Meets any 2 of 3 categories: Category 1 — Independent interpretation of test requiring independent interpretation; Category 2 — Discussion of management or test interpretation with external physician/QHP/appropriate source; Category 3 — Discussion of management or test interpretation with external physician/QHP/appropriate source (a second discussion or a discussion on a different topic from Category 2). Note: achieving "high" requires meeting 2 of the 3 category types, or can include review of extensive external records with an independent interpretation

Unique test clarification: Each unique test is counted once regardless of how many times it is repeated. For example, ordering a complete metabolic panel and a lipid panel counts as 2 unique tests. Ordering a CBC three times in one day counts as 1 unique test.

Independent interpretation: The provider must document their own interpretation of the test data (such as personally reviewing an ECG tracing or radiographic image), not simply review another provider's interpretation report. The independent interpretation must be documented in the encounter note.

External physician discussion: The discussion must be with a physician or qualified healthcare professional who is not in the same group practice. The discussion must be documented, including the identity of the other provider and the topic discussed. Simply leaving a message does not count — there must be an interactive exchange.

Documentation requirement: The encounter note must identify what data was reviewed, what tests were ordered, what independent interpretations were performed, and what discussions with external providers occurred. Referencing "reviewed labs" is insufficient — the specific tests reviewed should be identified.

Element 3: Risk of Complications and/or Morbidity or Mortality of Patient Management

This element evaluates the risk associated with the management decisions made during the encounter. Risk is assessed based on the management options selected, not the patient's underlying risk factors.

MDM Level	Risk of Management
Straightforward	Minimal risk of morbidity from additional diagnostic testing or treatment (e.g., rest, superficial dressing, OTC medications)
Low	Low risk of morbidity from additional diagnostic testing or treatment. Examples: OTC medications, minor surgery without identified risk factors, physical therapy, occupational therapy
Moderate	Moderate risk of morbidity from additional diagnostic testing or treatment. Examples: Prescription drug management; decision regarding minor surgery with identified patient or procedure risk factors; decision regarding elective major surgery without identified patient or procedure risk factors; diagnosis or treatment significantly limited by social determinants of health; drug therapy requiring intensive monitoring for toxicity
High	High risk of morbidity from additional diagnostic testing or treatment. Examples: Drug therapy requiring intensive monitoring for toxicity (in the context of a high-risk condition); decision regarding elective major surgery with identified patient or procedure risk factors; emergency major surgery; hospitalization or ICU care; decision not to resuscitate or to de-escalate care because of poor prognosis

Social determinants of health (SDOH): The inclusion of "diagnosis or treatment significantly limited by social determinants of health" at the moderate risk level was added to recognize that managing patients whose care is complicated by housing instability, food insecurity, lack of transportation, or other SDOH requires additional clinical complexity. Documentation must describe how the SDOH limits the diagnosis or treatment — a general statement that the patient has social challenges is insufficient.

Prescription drug management: Prescribing a new medication, changing a medication dose, or continuing a medication that requires monitoring qualifies as moderate risk. This is one of the most commonly met moderate risk criteria and is well documented when the assessment and plan include specific medication decisions.

Complete MDM Reference Table

Code	MDM Level	Problems (Element 1)	Data (Element 2)	Risk (Element 3)	Minimum 2 of 3 Required
99211	N/A	May not require provider presence	N/A	N/A	Nurse/staff visit
99202/99212	Straightforward	1 self-limited/minor problem	Minimal/no data	Minimal risk	2 of 3 at Straightforward
99203/99213	Low	2+ self-limited problems OR 1 stable chronic OR 1 acute uncomplicated	Meets 1 data category (Low)	Low risk	2 of 3 at Low
99204/99214	Moderate	1+ chronic with exacerbation OR 2+ stable chronic OR 1 undiagnosed new problem OR 1 acute with systemic symptoms	Meets 1 of 3 categories (Moderate)	Moderate risk	2 of 3 at Moderate
99205/99215	High	1+ chronic with severe exacerbation OR 1 life-threatening condition	Meets 2 of 3 categories (High)	High risk	2 of 3 at High

Time-Based Coding

Providers may select the E/M level based on total time instead of MDM. When time is used, MDM does not need to meet the level criteria — time alone determines the code.

Outpatient E/M Time Thresholds

Code	New Patient Time	Established Patient Time
99202	15-29 minutes	N/A
99203	30-44 minutes	N/A
99204	45-59 minutes	N/A
99205	60-74 minutes	N/A
99211	N/A	Does not require provider time
99212	N/A	10-19 minutes
99213	N/A	20-29 minutes
99214	N/A	30-39 minutes
99215	N/A	40-54 minutes

What Counts as Total Time

For outpatient E/M visits, total time includes all time on the date of the encounter spent by the billing provider on the following activities:

• Preparing to see the patient (review of records, tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals
• Documenting clinical information in the medical record
• Independently interpreting results
• Communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

Time does not include: Travel time, time spent on services that are separately reported (e.g., procedures billed with separate CPT codes), or time spent by clinical staff who are not the billing provider.

Documentation requirement: When billing based on time, the provider must document the total time spent and a brief description of the activities performed. Best practice is to document total time as a specific number (e.g., "Total time on date of encounter: 42 minutes") rather than a range. While not required, documenting a breakdown of time across activities strengthens the claim.

Prolonged Services (99417)

When the total time for an outpatient E/M visit exceeds the maximum time for 99205 (new patient) or 99215 (established patient), the add-on code 99417 is used for each additional 15 minutes.

99417 requirements:

• Can only be reported with 99205 or 99215 as the base code
• The base code must be selected based on time (not MDM)
• Each unit of 99417 represents an additional 15 minutes beyond the time threshold for the base code
• For new patients (99205): first 99417 at 75 minutes, second at 90 minutes, etc.
• For established patients (99215): first 99417 at 55 minutes, second at 70 minutes, etc.
• Time must be documented

Example: An established patient visit with 72 minutes of total provider time:

• Base code: 99215 (40-54 minutes)
• First 99417: 55-69 minutes
• Second 99417: 70-84 minutes
• Bill: 99215 + 99417 x2

Split/Shared Visits

Split/shared visits involve both a physician and a non-physician practitioner (NPP) — such as a nurse practitioner or physician assistant — from the same group practice providing services during the same encounter.

2026 Rules for Split/Shared Visits

Facility settings only: Split/shared visit billing applies only to facility settings (hospital inpatient, hospital outpatient, emergency department, observation). Office/outpatient visits cannot be billed as split/shared.

Substantive portion determines billing provider: The provider who performs the "substantive portion" of the visit bills the service. CMS defines the substantive portion as more than half of the total time spent by the physician and NPP combined.

Documentation requirements:

• Both the physician and NPP must document their individual contributions
• The medical record must support that both providers were involved
• The total time and each provider's time must be documented
• The provider performing the substantive portion bills the visit under their NPI

Important note on CMS rulemaking: CMS had initially proposed that the substantive portion be defined as the provider who performs the history, exam, or MDM (not time-based), but the final rule adopted the time-based definition. Organizations should verify the current CMS definition annually, as this has been a subject of ongoing rulemaking.

Hospital Inpatient and Observation Visit Codes

Initial Hospital Inpatient or Observation Care (99221-99223)

These codes are used for the first inpatient or observation encounter. Since 2023, CMS consolidated initial inpatient and initial observation codes into a single code set.

Code	MDM Level	Time
99221	Straightforward or Low	40 minutes
99222	Moderate	55 minutes
99223	High	75 minutes

Subsequent Hospital Inpatient or Observation Care (99231-99233)

Code	MDM Level	Time
99231	Straightforward or Low	25 minutes
99232	Moderate	35 minutes
99233	High	50 minutes

Hospital Inpatient or Observation Discharge (99238-99239)

Code	Time
99238	30 minutes or less
99239	More than 30 minutes

Discharge management includes final examination, discussion of hospital stay, instructions for continuing care, preparation of referral forms and prescriptions, and discharge records.

Same-Day Admit and Discharge (99234-99236)

When a patient is admitted and discharged on the same calendar date (applies to both inpatient and observation):

Code	MDM Level	Time
99234	Straightforward or Low	45 minutes
99235	Moderate	70 minutes
99236	High	85 minutes

Critical Care Services (99291-99292)

Critical care is defined as the direct delivery of medical care for a critically ill or critically injured patient whose illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration.

Time-Based Billing

Code	Time
99291	First 30-74 minutes
99292	Each additional 30 minutes

Critical care time does not need to be continuous. The provider must document total critical care time and should describe the nature of the critical illness and the specific critical care services provided.

What Counts as Critical Care Time

• Time spent directly managing the critically ill patient's care
• Time spent at the bedside or immediately available on the unit
• Time reviewing test results, imaging, and conferring with other staff about the patient's care
• Time documenting critical care services in the medical record

What Does NOT Count

• Time spent on separately reportable procedures (CPR, intubation, central line placement — these are billed separately)
• Time when the provider is not immediately available
• Time spent on floor/unit activities not directly related to the critical care patient

Documentation Requirements

Critical care documentation must include:

1. The condition making the patient critically ill
2. The total critical care time (specific minutes)
3. The nature of the critical care services provided
4. That the provider was personally and directly managing the patient's care

2026-Specific Updates and Considerations

Add-On Codes for Complexity

G2211 — Visit complexity inherent to E/M associated with medical care services that serve as the continuing focal point for all needed healthcare services: This add-on code, reportable with office/outpatient E/M visits (99202-99215), was implemented January 1, 2024. It is intended to recognize the additional resources associated with providing primary care and longitudinal care coordination. It may be reported when the visit is for a condition that the provider is managing as part of an ongoing patient-physician relationship, and the complexity of the medical decision-making is increased by the need to coordinate care with multiple providers or manage a condition that requires ongoing monitoring.

G2211 documentation: The medical record should reflect the ongoing nature of the provider-patient relationship and the coordination complexity. CMS has indicated that the code is intended primarily for primary care but is not limited to primary care specialties.

Telehealth E/M Coding

E/M services provided via telehealth use the same CPT codes as in-person services (99202-99215 for office/outpatient). The key differences:

• Place of Service (POS): POS 02 (telehealth) if the patient is at home; POS 10 (telehealth in patient's home) may be used depending on payer
• Modifier 95: Appended to indicate synchronous telehealth service
• Audio-only services: When permitted by payer, audio-only E/M services use modifier 93 and are typically reimbursed at a lower rate. CMS has extended audio-only coverage for certain E/M services but with limitations
• Documentation: Telehealth encounters should document the modality (audio-video vs. audio-only), that the technology functioned adequately for clinical assessment, and that the patient consented to the telehealth visit

CMS Payment Adjustments

CMS periodically adjusts the relative value units (RVUs) for E/M codes. For 2026, providers should verify the current work RVUs, practice expense RVUs, and malpractice RVUs for each E/M code, as these directly affect reimbursement. The Medicare Physician Fee Schedule final rule, published annually in the Federal Register, contains the definitive RVU values.

Documentation Best Practices by Code Level

99212 (Straightforward MDM)

Typical encounter: A patient presents for a simple, self-limited problem such as a cold, insect bite, or prescription refill for a stable medication.

Documentation should include:

• Chief complaint
• Brief HPI relevant to the problem
• Focused exam (as clinically appropriate, not required for code selection)
• Assessment: identification of the self-limited problem
• Plan: OTC medication recommendation, rest, follow-up if not improving

Common documentation errors: Documenting sufficient complexity for a level 3 visit but billing level 2 (undercoding), or billing level 2 when the documentation supports only 99211 (overcoding for a nurse-only visit).

99213 (Low MDM)

Typical encounter: A patient with one stable chronic illness (e.g., well-controlled hypertension) presenting for management, or a patient with two self-limited problems.

Documentation should include:

• Chief complaint
• HPI addressing the chronic condition(s) or acute problem(s)
• Exam as clinically appropriate
• Assessment: specific identification of the stable chronic condition(s) or acute problem(s)
• Plan: continuation of current medication, monitoring plan, or treatment for uncomplicated acute problem
• At least one data element from the Low category, if used as one of the two qualifying elements

Common documentation errors: Failing to specify whether a chronic condition is "stable" versus having an exacerbation (which would qualify for level 4). Vague assessments like "diabetes — continue meds" do not establish stability — the note should indicate "type 2 diabetes — well controlled, A1c 6.8%, continue current regimen."

99214 (Moderate MDM)

Typical encounter: A patient with a chronic illness experiencing mild exacerbation or progression, a patient with two or more stable chronic illnesses, or a patient with a new undiagnosed problem with uncertain prognosis.

Documentation should include:

• Chief complaint
• HPI addressing the problem(s) with attention to changes, progression, or new symptoms
• Exam as clinically appropriate
• Assessment: specific identification of the exacerbation, progression, or undiagnosed problem
• Plan: medication adjustment, new prescription, additional diagnostic testing, referral
• Moderate risk element (e.g., prescription drug management)
• Moderate data element if needed as one of the two qualifying elements

Common documentation errors: Billing level 4 for a stable chronic illness without documenting exacerbation or progression. "Hypertension — adjusted medication" supports level 4 only if the note explains why the adjustment was needed (exacerbation, side effects, inadequate control). Simply changing a medication dose without context does not automatically qualify as moderate complexity.

99215 (High MDM)

Typical encounter: A patient with a chronic illness in severe exacerbation, or a condition posing a threat to life or bodily function.

Documentation should include:

• Chief complaint
• Detailed HPI documenting the severity of the presentation
• Exam as clinically appropriate — typically more extensive given the severity
• Assessment: clear documentation of severe exacerbation, threat to life, or threat to bodily function
• Plan: high-risk management decisions (hospitalization consideration, emergency intervention, drug therapy requiring intensive monitoring in a high-risk context)
• High data elements if needed as one of the two qualifying elements

Common documentation errors: Using "severe" without clinical context. "COPD — severe exacerbation" needs supporting documentation: oxygen saturation level, respiratory rate, need for emergent nebulizer treatment, consideration of hospitalization, or similar indicators of severity.

Audit-Proofing E/M Documentation

The Medical Necessity Bridge

Every E/M encounter must establish medical necessity — the connection between the patient's presenting problem and the services provided. Medical necessity is not a separate documentation element, but it must be evident from the encounter note as a whole. The assessment should explain why the services were needed, and the plan should explain what was done about it.

Specificity Over Volume

Under the current E/M guidelines, a lengthy note does not justify a higher E/M level. A concise note that clearly documents the problems addressed, the data reviewed, and the risk of management will support the code better than a three-page note filled with templated language and copied-forward information. Auditors are trained to look past template language and focus on provider-specific clinical content.

Avoid Copy-Forward Without Updates

Electronic health records make it easy to copy forward prior notes. While not prohibited, copying forward without updating the assessment and plan to reflect the current encounter creates audit vulnerability. Each encounter note should reflect the clinical reality of that specific visit, not the visit six months ago.

Document Medical Decision Making Explicitly

Do not force auditors (or AI systems) to infer MDM from the note. State the clinical reasoning. Instead of "continue current medications," write "Type 2 diabetes with A1c increased from 7.2% to 8.1% — adding metformin XR 500mg daily, will recheck A1c in 3 months, discussed dietary modifications and referred to diabetes educator." This sentence establishes a chronic illness with progression (Element 1), prescription drug management (Element 3 — moderate risk), and clinical reasoning for the plan.

Time Documentation

If billing based on time, document the total time clearly. "Spent approximately 35 minutes" is acceptable but less defensible than "Total time on date of encounter: 37 minutes." If prolonged services are billed, detailed time documentation is critical — auditors will scrutinize 99417 claims closely.

Specialty-Specific Considerations

Emergency Medicine

Emergency department E/M codes (99281-99285) use a separate MDM framework. ED physicians should reference the ED-specific code definitions, which differ from office/outpatient codes in their MDM criteria and time thresholds.

Consultations

Medicare does not recognize consultation codes (99241-99245, 99251-99255). Services that would have been billed as consultations are instead billed using the appropriate new or established patient E/M codes (outpatient) or initial hospital care codes (inpatient). Some commercial payers still recognize consultation codes — verify payer-specific requirements.

Preventive Medicine

Annual wellness visits (G0438, G0439) and preventive medicine codes (99381-99397) are distinct from problem-oriented E/M codes. When a significant, separately identifiable E/M service is provided during a preventive visit, the problem-oriented E/M code may be billed in addition to the preventive code with modifier 25.

Summary

The E/M documentation framework is built on clarity, specificity, and clinical reasoning. The 2021 redesign simplified the documentation requirements by eliminating mandatory history and exam elements, but it increased the importance of documenting MDM with precision. Every E/M encounter note should clearly answer three questions: What problems were addressed? What data was reviewed and analyzed? What are the risks of the management decisions made? When these three questions are answered with specificity and clinical reasoning, the documentation will support the appropriate E/M level — whether the code is selected by a human coder or an AI coding system.