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Summary: The 2026 MDM table for office and outpatient E/M (99202 to 99215) is unchanged: a level is met when 2 of 3 elements (problems, data, risk) meet or exceed it. Time-based coding uses minimum times that must be met or exceeded (for example 30 minutes for 99214). Prolonged services use 99417 or Medicare G2212. For 2026, Medicare pays G2211 with home visits and exempts E/M from the -2.5% efficiency adjustment. Includes an E/M level calculator.
The 2026 MDM table sorts office and outpatient E/M visits into four levels of medical decision making: straightforward, low, moderate and high. A visit qualifies for a level when it meets or exceeds 2 of the 3 MDM elements: problems addressed, data reviewed and analyzed, and risk of patient management. Straightforward supports 99202 or 99212, low supports 99203 or 99213, moderate supports 99204 or 99214, and high supports 99205 or 99215. You can instead code by total time on the date of the encounter, using minimum times that must be met or exceeded, such as 30 minutes for 99214.
This guide gives the full 2026 E/M MDM table with the data categories, the time table, prolonged service rules, what changed for 2026 (G2211, the efficiency adjustment and telehealth), documentation tips and an E/M level calculator.
2026 MDM table for office and outpatient E/M
| MDM level | Problems addressed | Data reviewed and analyzed | Risk of patient management | New / established |
|---|---|---|---|---|
| Straightforward | 1 self-limited or minor problem | Minimal or none | Minimal risk from additional diagnostic testing or treatment | 99202 / 99212 |
| Low | 2 or more self-limited or minor problems; or 1 stable chronic illness; or 1 acute, uncomplicated illness or injury; or 1 stable acute illness; or 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level care | Limited: meet 1 of 2 categories. Category 1: any combination of 2 from review of prior external notes from each unique source, review of the result of each unique test, ordering of each unique test. Category 2: assessment requiring an independent historian | Low risk from additional diagnostic testing or treatment | 99203 / 99213 |
| Moderate | 1 or more chronic illnesses with exacerbation, progression or side effects of treatment; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute, complicated injury | Moderate: meet 1 of 3 categories. Category 1: any combination of 3 from external notes, unique test results, unique tests ordered, independent historian. Category 2: independent interpretation of a test performed by another physician or QHP. Category 3: discussion of management or test interpretation with an external physician, QHP or appropriate source | Moderate risk, for example prescription drug management; decision regarding minor surgery with identified patient or procedure risk factors; decision regarding elective major surgery without risk factors; diagnosis or treatment significantly limited by social determinants of health | 99204 / 99214 |
| 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 | Extensive: meet 2 of 3 categories. Category 1: any combination of 3 from external notes, unique test results, unique tests ordered, independent historian. Category 2: independent interpretation of a test. Category 3: discussion of management or test interpretation with an external physician, QHP or appropriate source | High risk, for example drug therapy requiring intensive monitoring for toxicity; decision regarding elective major surgery with risk factors; decision regarding emergency major surgery; decision regarding hospitalization or escalation of hospital-level care; decision not to resuscitate or to de-escalate care because of poor prognosis; parenteral controlled substances | 99205 / 99215 |
Source: AMA CPT E/M services guidelines, Table 1: Levels of medical decision making. The MDM framework is unchanged for 2026. 99211 does not use MDM or time.
2026 E/M level calculator
2026 E/M level calculator (MDM and time)
Enter what the note supports. The tool scores each MDM element, applies the 2-of-3 rule, checks total time against the CPT minimums, and shows prolonged service units.
1. Problems addressed
2. Data reviewed and analyzed
3. Risk of patient management
Based on the AMA CPT office or other outpatient E/M guidelines (MDM table and minimum times that must be met or exceeded) and CMS prolonged service rules (G2212). Final code selection is the billing provider's responsibility; check payer policy. This tool does not store any data.
2026 E/M time table (minimum times)
Since 2024, CPT lists a single minimum time for each office visit level rather than a range. The total time on the date of the encounter must meet or exceed that minimum.
| Code | Patient | MDM level | Total time must meet or exceed |
|---|---|---|---|
| 99202 | New | Straightforward | 15 minutes |
| 99203 | New | Low | 30 minutes |
| 99204 | New | Moderate | 45 minutes |
| 99205 | New | High | 60 minutes |
| 99212 | Established | Straightforward | 10 minutes |
| 99213 | Established | Low | 20 minutes |
| 99214 | Established | Moderate | 30 minutes |
| 99215 | Established | High | 40 minutes |
Older guides still show ranges such as "30 to 39 minutes" for 99214. Those ranges were removed from CPT; any time from 30 minutes upward supports 99214 until the next level's minimum is met. Source: AAFP, time and MDM levels for E/M codes.
What counts toward total time
- Preparing to see the patient, such as reviewing tests and records.
- Obtaining or reviewing a separately obtained history.
- Performing the exam, counseling and educating the patient, family or caregiver.
- Ordering medications, tests or procedures, and referring or communicating with other professionals (when not separately reported).
- Documenting in the medical record, and independently interpreting results (when not separately reported).
- Care coordination (when not separately reported). Do not count travel, staff time, or time on separately billed services.
Prolonged services in 2026: 99417 vs G2212
| Payer rule | New patient (99205) | Established patient (99215) | Each additional unit |
|---|---|---|---|
| CPT +99417 (most commercial payers) | 75 minutes | 55 minutes | Each full 15 minutes beyond the 99205 or 99215 minimum |
| Medicare G2212 | 89 minutes | 69 minutes | Each additional full 15 minutes |
Prolonged services apply only when the level is selected by time and the visit is level 5. Medicare does not accept 99417 and counts its thresholds from the end of the old time ranges, which is why G2212 starts later. Source: AAFP.
What's new in E/M coding for 2026
| Change | What it means | Source |
|---|---|---|
| MDM table and office E/M codes | No change to the MDM table or to 99202 to 99215 for 2026 | AMA CPT, CMS |
| G2211 complexity add-on | Now payable with home or residence E/M visits (99341 to 99350) as well as office visits | CMS MM14315 |
| Efficiency adjustment | A -2.5% cut to work RVUs of non-time-based services; time-based codes, including E/M, are exempt | CMS final rule, CAPC |
| Conversion factor | $33.40 (non-qualifying APM) and $33.57 (qualifying APM) | CMS final rule, CAPC |
| Telehealth | Frequency limits for subsequent hospital, nursing facility and critical care visits removed permanently | CMS final rule, CAPC |
| Virtual direct supervision | Allowed permanently for applicable incident-to services, using real-time audio and video | CMS MM14315 |
Sources: CMS MLN MM14315, CY 2026 PFS final rule summary and CAPC summary of the 2026 fee schedule. For the payment impact on therapy practices, see 2026 Medicare conversion factor impact.
G2211 basics
G2211 is a Medicare add-on for the extra complexity of an ongoing, longitudinal relationship with the patient for a serious or complex condition. Since 2025 it can be paid when the E/M visit has modifier 25 only if the other same-day service is an annual wellness visit, vaccine administration or a Medicare Part B preventive service.
How the 3 MDM elements work
1. Number and complexity of problems addressed
Count a problem only if you evaluated or treated it at the visit. A diagnosis on the problem list, or one managed by another clinician and only noted, does not count. Notating that another professional is managing a problem, without more, is not addressing it.
2. Amount and complexity of data reviewed and analyzed
Data is counted by category. A unique test is defined by its CPT code, so serial results of the same test count once. Ordering a test and later reviewing its result count as one element, not two. An independent historian is a parent, spouse, guardian or witness who gives the history because the patient cannot; translation services do not count.
3. Risk of complications, morbidity or mortality
Risk reflects the management options you considered, including those the patient declined. Prescription drug management usually supports moderate risk; a decision about hospitalization supports high risk. Document the options and the decision.
MDM vs time: which should you use?
| Use MDM when | Use time when |
|---|---|
| The visit addresses several problems or high-risk decisions in a short visit | Counseling, coordination or documentation made the visit long |
| Data review, independent interpretation or external discussion was substantial | The problem set is simple but total time was high |
| You do not want to track minutes | You can document total time on the date of the encounter |
Pick whichever method supports the higher level, then document that method. If you use MDM, you do not need to record time; if you use time, record the total minutes and what they included.
E/M documentation checklist
- Name each problem addressed and its status (stable, worsening, new, uncertain prognosis).
- List external notes by source, tests reviewed and tests ordered.
- Note an independent historian and why one was needed.
- Document independent interpretation of a test in your own words.
- Record discussions with external physicians or other professionals.
- Describe the management options and risk (prescription drugs, surgery, hospitalization).
- For time-based coding, state the total time on the date of the encounter and the activities included.
- Add modifier 25 only for a significant, separately identifiable E/M on the same day as a procedure.
Comparing two common levels? See 99213 vs 99214. For therapy note requirements, see the PT documentation cheat sheet and the PT CPT codes reference sheet.
Appropriate Use Criteria (AUC) program: current status
CMS paused the Medicare AUC program for advanced diagnostic imaging effective January 1, 2024, rescinded the regulations at 42 CFR 414.94, and told providers to stop reporting AUC consultation information on claims. It is not an active 2026 claim requirement. Source: CMS AUC program page.
How SPRY supports documentation and revenue cycle workflows
Accurate coding starts with clear documentation and continues through claims, payment and denial follow-up. SPRY brings clinical and revenue cycle work into one system with physical therapy software, revenue cycle management, denial management and telehealth.
Frequently asked questions
What is the MDM table for 2026?
It is the AMA CPT table that defines straightforward, low, moderate and high medical decision making by problems addressed, data reviewed and analyzed, and risk. A level is met when 2 of the 3 elements meet or exceed it. The table did not change for 2026.
What are the E/M time thresholds for 2026?
New patients: 15 minutes for 99202, 30 for 99203, 45 for 99204 and 60 for 99205. Established patients: 10 minutes for 99212, 20 for 99213, 30 for 99214 and 40 for 99215. Each is a minimum that must be met or exceeded.
Are E/M time ranges still used in 2026?
No. CPT replaced the ranges with single minimum times in 2024. For example, 99214 needs at least 30 minutes, with no upper limit within the code.
How many data elements are needed for moderate MDM?
Meet 1 of 3 categories: any combination of 3 items from external notes, unique test results, unique tests ordered and an independent historian; or an independent interpretation of a test; or a discussion of management with an external physician or QHP.
When can I bill 99417 or G2212?
Only for level 5 visits coded by time. CPT 99417 starts at 75 minutes for 99205 and 55 minutes for 99215. Medicare uses G2212, which starts at 89 and 69 minutes.
What changed for E/M coding in 2026?
The MDM table and office codes did not change. Medicare now pays G2211 with home and residence visits, exempts E/M and other time-based codes from the -2.5% efficiency adjustment, and set conversion factors of $33.40 and $33.57.
Does MDM require documentation of total visit time?
No. When you select the level by MDM, time is not required. When you select by time, document the total time on the date of the encounter.
Is the Appropriate Use Criteria (AUC) program required in 2026?
No. CMS paused the program on January 1, 2024, rescinded the regulations and stopped requiring AUC information on Medicare claims.
Does prescription drug management always mean moderate MDM?
No. It supports moderate risk, but you still need a second element, problems or data, at moderate or higher to bill moderate MDM.
Sources
- AMA: CPT E/M services guidelines and MDM table
- AAFP: time and MDM levels for E/M codes
- CMS MLN MM14315: CY 2026 Medicare Physician Fee Schedule final rule summary
- CAPC: 2026 physician fee schedule finalized
- CMS: Appropriate Use Criteria program
Last reviewed: October 2026. Coding rules vary by payer and can change; verify current CPT and CMS guidance before submitting claims.
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