E/M Coding: Key Components (History, Exam, MDM, Time, Counseling)

Evaluation & Management (E/M) Code Selection

Since 2021, office/outpatient E/M levels (99202–99215) are based primarily on Medical Decision Making (MDM) or Total Time. History and Exam are no longer scored but must be documented as medically appropriate.

Three Pillars of MDM

Element	Levels
Number & Complexity of Problems Addressed	Minimal (1 self-limited) → Low (2+ self-limited / 1 stable chronic) → Moderate (1+ chronic w/ exacerbation / 2+ stable chronic / undiagnosed new problem w/ uncertain prognosis) → High (1+ chronic w/ severe exacerbation / acute or chronic illness posing threat to life/bodily function)
Amount/Complexity of Data Reviewed	Minimal (none/1 test) → Low (2+ tests / 1 external note / 1 independent historian) → Moderate (3+ tests / 1+ external note + test / independent historian + test / discussion of management w/ external physician) → High (3+ category 2 items)
Risk of Complications/Morbidity/Mortality	Minimal (OTC mgmt) → Low (prescription mgmt) → Moderate (prescription mgmt w/ monitoring / minor surgery) → High (drug therapy requiring intensive monitoring / major surgery / decision to hospitalize / escalate care)

Total Time

Includes all face-to-face and non-face-to-face activities on the date of encounter: history review, counseling, ordering/interpreting tests, documentation, care coordination. Time thresholds define code levels (e.g., 99214 = 30–39 min established patient).

Counseling & Coordination of Care

When >50% of the encounter is counseling/coordination, time may be the controlling factor. Document topics discussed and medical necessity.

Documentation Essentials

• Chief complaint & HPI (pertinent positives/negatives).
• Relevant ROS, PFSH (as clinically indicated).
• Focused or comprehensive exam (document findings).
• Assessment & plan with clear MDM rationale.
• Time statement if time-based coding: “Total time 40 minutes; >50% counseling.”

Other E/M Settings

Emergency department, hospital inpatient/observation, nursing facility, and home visits retain the three-component (History, Exam, MDM) framework; consult current CPT/AMA guidelines for specifics.