The 2025 updates to Evaluation and Management (E/M) coding bring significant changes that affect how providers document and bill for patient visits. Understanding these changes is crucial for maintaining compliance and optimizing reimbursement.
Overview of 2025 E/M Changes
The latest E/M coding guidelines continue the shift toward time-based and medical decision-making (MDM) focused documentation, moving further away from the traditional history and physical examination requirements that have guided coding for decades.
Key Changes for Office/Outpatient Visits
For established patient office visits (99211-99215) and new patient visits (99202-99205), providers can now select the level of service based solely on either:
- Total time spent on the date of the encounter, or
- Medical decision-making complexity
This flexibility allows providers to choose the method that best reflects the work performed during each encounter.
Time-Based Coding Updates
When using time as the basis for code selection, the 2025 guidelines clarify that time includes:
- Face-to-face time with the patient and family
- Time spent reviewing records and test results
- Time spent documenting the encounter
- Time spent coordinating care with other providers
Important: Time spent on activities that occur outside the date of service (such as follow-up calls on subsequent days) cannot be counted toward the total time for code selection.
Medical Decision-Making (MDM) Framework
The MDM framework evaluates three elements:
- Number and complexity of problems addressed: Considers the severity and number of diagnoses or conditions managed during the encounter
- Amount and complexity of data reviewed: Includes review of tests, records, and independent interpretation of images or specimens
- Risk of complications and morbidity: Assesses the risk associated with diagnostic procedures, treatment options, and patient management decisions
To qualify for a particular level of MDM, you must meet the requirements for two of the three elements.
Documentation Best Practices
To support your code selection under the 2025 guidelines:
- For time-based coding: Document the total time spent and briefly describe the activities performed
- For MDM-based coding: Clearly document the complexity of problems addressed, data reviewed, and risk considerations
- Use templates and prompts in your EHR to ensure all required elements are captured
- Train providers on the specific documentation requirements for each coding method
Prolonged Services
The 2025 updates also refine the use of prolonged service codes (99417 for outpatient, 99418 for inpatient). These add-on codes can be used when time significantly exceeds the typical time for the highest-level E/M code in the category.
Impact on Reimbursement
These changes can positively impact reimbursement when providers accurately document the complexity of their work. However, underdocumentation or failure to capture all relevant time and MDM elements can result in lost revenue.
Action Steps for Your Practice
- Educate all providers on the 2025 E/M guidelines
- Update EHR templates to support both time-based and MDM-based documentation
- Conduct regular audits to ensure compliance and identify documentation gaps
- Monitor coding patterns and reimbursement trends to optimize performance
- Consider working with coding specialists to review complex cases
Staying current with E/M coding changes is essential for compliance and revenue optimization. If your practice needs assistance implementing these changes or training your team, professional coding support can help ensure a smooth transition.