MLN: 2021 E/M Office Visit Coding Revisions
Reference to the 2021 CPT E/M office visit (99202-99215) code revisions: history and exam no longer used for code selection; medical decision making or time controls.
Primary source
MLN Booklet — Evaluation and Management Services Guide →https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
Verified May 23, 2026 · This is the authoritative regulator URL. The summary below is a research aid; the linked source controls.
Additional sources
The CY2021 Physician Fee Schedule Final Rule adopted the 2021 AMA CPT E/M office visit code revisions for Medicare effective January 1, 2021.
Major changes:
- History and physical exam no longer drive code selection for office visits (99202-99215). They remain medically necessary and must be documented, but their granular elements are not what determine the level.
- Code level is selected by either Medical Decision Making (MDM) or total time on the date of the encounter.
- MDM table has three elements: number/complexity of problems addressed; amount/complexity of data reviewed and analyzed; risk of complications, morbidity, or mortality of patient management.
- Time is the total time spent by the reporting practitioner on the date of the encounter — including non-face-to-face activities (reviewing tests, ordering, documenting, counseling, care coordination, communicating with other practitioners) but not separately reportable services.
- 99201 deleted (level 1 new patient).
- Prolonged services code 99417 added for time above the 99205/99215 threshold.
The 2023 revisions extended the same framework to hospital inpatient/observation, consults, emergency department, nursing facility, home, domiciliary, and prolonged service codes. The MLN E/M Services Guide reflects the consolidated framework.
Use this in your workspace
D3rx assembles the documentation linked to this regulation, walks the practical decisions in plain English, and stores the artifacts against the .gov sources cited above. It is an administrative research aid, not a substitute for counsel.
Related regulations
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- RegulationMLN: Time-Based E/M CodingReference to the CMS rules for selecting an E/M code by total time on the date of the encounter, including the activities that count and prolonged service add-ons.
- RegulationModifier 25: Significant, Separately Identifiable E/M ServiceModifier 25 is appended to an E/M code when the E/M is significant and separately identifiable from another procedure or service performed on the same day by the same provider.
- RegulationNCCI Chapter 11: Evaluation and Management ServicesNCCI policy on bundling and separately reporting E/M services with procedures, including modifier 25 use and global surgical package interactions.
- Glossary99214 vs 99215The two most common established-patient office E/M levels; 99214 represents moderate complexity and 99215 high complexity.
- GlossaryCritical Care (99291-99292)CPT codes for evaluation and management of a critically ill or critically injured patient, time-based.
- GlossaryDocumentation CloningThe practice of copying prior or template-generated documentation into a new encounter note without updating it for the current visit.
- GlossaryDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- GlossaryE/M CodingEvaluation and Management codes (99202-99499) used to bill office, hospital, and other professional visits.
Last reviewed May 23, 2026 · Citation verified May 23, 2026
Research aid, not legal advice. This summary is an administrative research aid prepared by D3rx. It does not certify compliance, provide legal advice, replace counsel, or guarantee an audit outcome. For authoritative regulatory text follow the primary source link at the top of this page. The practice remains responsible for reviewing, adopting, and maintaining its compliance program.