The American Medical Association (AMA) and CMS have introduced significant updates to Evaluation and Management (E/M) coding guidelines for 2026. These changes aim to reduce administrative burden while improving payment accuracy.
Major changes in 2026 E/M coding
1. Revised time thresholds
Time-based billing thresholds have been adjusted, and many codes now require slightly more total time to qualify for higher levels. Documenting total time — both face-to-face and non-face-to-face activities — is more important than ever.
2. Enhanced medical decision making (MDM) guidelines
The MDM table has been refined with clearer definitions for:
- Number and complexity of problems addressed
- Amount and/or complexity of data to be reviewed and analyzed
- Risk of complications, morbidity, or mortality
3. New documentation standards
Providers must clearly document the medical necessity of the visit level. Vague notes like “patient doing well” are no longer sufficient for higher-level E/M codes.
Practical billing strategies for 2026
For providers
- Use the new MDM grid during patient encounters
- Document all time spent on the date of service (chart review, ordering tests, care coordination)
- Be specific about the severity and number of problems addressed
For billers & coders
- Double-check time documentation before submitting claims
- Watch for upcoding risk — payers are increasing audits
- Confirm diagnosis specificity with our ICD-10 search
Common pitfalls to avoid
- Relying solely on time without supporting MDM elements
- Using outdated 2021 templates without updates
- Inconsistent documentation across providers
Pro tip
How Enhancely supports E/M coding
Our team audits recent E/M claims for under- and over-coding, and our E/M level advisor — currently in development — will offer guideline-based level suggestions.
Next steps for your practice
- Update your EHR templates to reflect 2026 guidelines
- Train all providers and billing staff
- Schedule an internal audit of recent E/M claims
- Book a free consultation with our revenue optimization team
“Accurate E/M coding isn’t just about compliance — it’s about fairly compensating the complex cognitive work our providers do every day.”