Evaluation and management (E/M) code selection rules have been stable since 2021, but the billing rules around them change every year. This cheat sheet puts the 2026 E/M coding guidelines in one place, from office and emergency department (ED) visit levels to Medicare telehealth billing, G2211, and what changes in 2027.
Payers are looking harder at E/M levels, and the guidelines still leave room for interpretation. Your providers need to document consistently and follow the same leveling philosophy, so your E/M distribution holds up when a payer compares it to peers. If a level is challenged, you want to show it was chosen the same way every time.
Medical decision making (MDM) and total time replaced history and exam as the basis for office visit levels in January 2021, and Current Procedural Terminology (CPT) extended a similar framework to hospital, ED, nursing facility, and home visits in January 2023 (1).
Physicians and other qualified health care professionals (QHPs) select an office visit level using one of two methods:
You still document a medically appropriate history and exam, but they no longer drive the level. Use whichever method better reflects the work performed, and make sure the documentation clearly supports the one you used.
|
Code |
Patient Type |
MDM Level |
Minimum Time |
|---|---|---|---|
|
99202 |
New |
Straightforward |
15 min |
|
99203 |
New |
Low |
30 min |
|
99204 |
New |
Moderate |
45 min |
|
99205 |
New |
High |
60 min |
|
99211 |
Established |
N/A* |
N/A* |
|
99212 |
Established |
Straightforward |
10 min |
|
99213 |
Established |
Low |
20 min |
|
99214 |
Established |
Moderate |
30 min |
|
99215 |
Established |
High |
40 min |
*99211 doesn't require a physician or QHP to be present and isn't selected by MDM or time.
Prolonged services add-ons apply only to 99205 and 99215 selected by time. CPT +99417 is reported per additional 15 minutes starting at 75 minutes for 99205 or 55 minutes for 99215. Medicare doesn't accept 99417 and uses Healthcare Common Procedure Coding System (HCPCS) code G2212 instead, which starts at 89 minutes for 99205 and 69 minutes for 99215 (1).
ED E/M codes 99281-99285 use the same MDM framework, with one difference: time doesn't count. Levels run from straightforward (99282) to high (99285). Like 99211, 99281 may not require a physician or QHP to be present (2).
CPT codes 98000-98016 are the codes the AMA created specifically for telemedicine. Medicare largely doesn't pay them, and other payers vary, so check each contract first (3). For Medicare patients, bill the standard office E/M codes (99202-99215) with a telehealth place of service (POS) code and modifier:
The 2026 Medicare Physician Fee Schedule (MPFS) final rule didn't change how office levels are selected. It did extend G2211 to home or residence visits and permanently removed telehealth frequency limits for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations (6).
G2211, payable since January 1, 2024, reflects the extra work of an ongoing care relationship, where you're the continuing focal point for a patient's care or you're managing a single serious or complex condition over time (7).
G2211 doesn't fit one-time or time-limited visits, so don't add it by default.
The Consolidated Appropriations Act, 2026, extended Medicare telehealth flexibilities through December 31, 2027 (8). Until then, non-behavioral health telehealth has no geographic restrictions, the patient's home counts as an originating site, audio-only visits are allowed, FQHCs and RHCs can serve as distant site providers, and all eligible practitioners can furnish telehealth.
Behavioral and mental health telehealth works differently. Audio-only behavioral health care is now permanent when the patient can't use or doesn't consent to video, and the in-person visit requirement for most mental health telehealth services is delayed until January 1, 2028 (8).
The 2027 CPT code set adds 299 codes, deletes 80, and revises 74 (9). For E/M, the biggest change is in maternity care. Starting January 1, 2027, the traditional global maternity codes are deleted and replaced with phase-specific reporting for antepartum, delivery, and postpartum care (10). Antepartum visits are reported individually with E/M codes, so each prenatal visit is leveled by MDM or total time and needs documentation that supports that level (11).
If your team has coded prenatal care under one global code for years, update templates and provider education before January, and plan for more E/M claims.
Four other items to track:
Each change above is one more rule your coders have to apply, and a missed update can repeat across hundreds of encounters.
While computer-assisted coding (CAC) tools suggest codes for a coder to review and approve, Nym's autonomous medical coding engine codes the encounter and routes it to billing with no human intervention. While machine learning (ML)-only engines need new data to retrain before they reflect a guideline change, which delays the update, Nym's rules-based approach updates when the guidelines change, so annual AMA and CMS updates take effect without a retraining cycle.
Unlike black box AI solutions, Nym's engine provides a transparent audit trail for every code assignment. That gives you a record of consistent E/M capture across encounters, so when a payer questions a level, your team can point to the documentation and guideline behind it. Encounters with missing or ambiguous documentation go to your coders with the specific issue flagged. At Inova, autonomous medical coding increased average charges per ED encounter by more than 10% through more complete, guideline-consistent capture of bedside procedures and E/M levels.
See how Nym's engine codes your E/M encounters, with an audit trail behind every code.