• What’s new with E/M coding? This chart can help you remember

    The most consequential changes to office/outpatient evaluation and management (E/M) coding in more than two decades took effect Jan. 1. Physicians and other qualified health professionals will now be able to level visits based solely on either medical decision making (MDM) or total time. The ways MDM and total time are calculated have changed somewhat, and will probably take some getting used to, but the good news is that the supporting documentation burden should be lower. Here’s a chart that can help you quickly remember what’s new this year compared with last year:


    • Number and complexity of problems addressed

    • Amount and/or complexity of data to be reviewed and analyzed

    • Risk of complications and/or morbidity or mortality

    • Total time (including non-face-to-face time) on date of visit; can be used for any visit

    • Only required as medically appropriate and not part of code level selection


    • Number of diagnoses or management options

    • Amount and/or complexity of data to be reviewed

    • Risk of complications and/or morbidity or mortality

    • Typical time face-to-face; only used when counseling and/or coordination of care dominate encounter

    • Key elements in selection of level of service

    For more on the coding changes, see the following FPM articles:

    Watch for an article on coding level 4 visits, specifically, in the upcoming January/February issue of FPM.

    Posted on Jan 04, 2021 by FPM Editors

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.