Evaluation and Management (E/M) Coding Updates for 2025

Medical coder at desk reviewing EHR notes and coding manuals with payer policy screens and certification card visible

2025 brings renewed focus on E/M coding clarity, payer variability, and documentation driven by continuing AMA and CMS refinements. This article explores key E/M updates, practical documentation and audit strategies, how changes affect remote and in‑office coding jobs, and steps to leverage updates for career growth in medical coding and billing across the United States.

Why 2025 E/M Changes Matter for Coders and Billers

The E/M coding changes for 2025 aren’t a sudden storm; they’re the latest weather pattern in a climate that shifted dramatically back in 2021. For those of us in the trenches of coding and billing, understanding this evolution is the key to navigating the daily challenges of our jobs. It’s not just about memorizing new rules. It’s about understanding the “why” behind them, because that’s what separates a good coder from a great one and a paid claim from a frustrating denial.

Let’s quickly rewind. The 2021 E/M overhaul was a landmark event. It finally freed us from the rigid, component-based counting of history and exam elements for office visits. Instead, the American Medical Association (AMA) and CMS gave us a more logical choice: select the E/M level based on either the complexity of Medical Decision Making (MDM) or the total time spent on the date of the encounter. This was a huge step toward aligning documentation with clinical thought processes. But it wasn’t a one-and-done fix. Since then, both the AMA and CMS, along with major commercial payers, have been in a continuous cycle of refinement, releasing clarifications and updated guidance to address gray areas and unforeseen scenarios. The changes we’re seeing through 2025 are the next logical step in that process.

So, why do these incremental clarifications and payer-specific policies matter so much to your daily work? Because the devil is truly in the details. A seemingly minor tweak in the definition of what constitutes “data analysis” for MDM can be the difference between a level 3 and a level 4 visit. This has direct consequences that ripple through the entire revenue cycle.

  • Audit Risk: Every clarification creates a new benchmark for auditors. Payers are actively using data analytics to flag providers whose billing patterns don’t align with these updated norms. What was considered a safe coding practice in 2024 might now trigger an audit, putting revenue and compliance at risk.
  • Denials and Revenue Integrity: Commercial payers are notorious for developing their own interpretations of CPT and CMS guidelines. A policy bulletin from a single major insurer can introduce a new documentation requirement or modifier rule that, if missed, leads to a cascade of denials. This directly impacts cash flow and increases the administrative burden of appeals.
  • Clinical Documentation Improvement (CDI) Priorities: With MDM as the primary driver for E/M levels, the partnership between coders and clinicians is more critical than ever. Our job is shifting. We must now guide providers to document their thought processes clearly, ensuring the “why” behind their decisions is evident in the medical record. This makes us key players in documentation quality.
  • Telehealth Persistence: Virtual care is a permanent part of the healthcare landscape, but reimbursement policies are still a moving target. Payers continue to adjust rules for place of service, appropriate modifiers, and what constitutes a valid telehealth encounter, especially for audio-only services. Staying on top of these changes is essential for clean claims.

These shifts fundamentally change the responsibilities of coders and billers, whether working remotely or in an office. Your role is no longer just about assigning a code based on a finished note. It’s about proactive surveillance and communication. Accuracy and compliance now depend on your ability to be a knowledge hub for your organization. This means you must diligently track payer policy bulletins and Local Coverage Determinations (LCDs) from your region’s Medicare Administrative Contractor (MAC). It also means collaborating with your IT or practice management team to ensure your organization’s EHR templates are designed to capture the necessary details for MDM and time-based billing, rather than hindering good documentation with outdated, rigid formats.

Failing to adapt to these nuances has downstream consequences that go far beyond a single denied claim. Inaccurate E/M coding can skew the data used for risk-adjustment calculations, potentially affecting the practice’s reimbursement rates in value-based care contracts. It can also impact quality reporting metrics, which are increasingly tied to financial incentives. By mastering these evolving guidelines, you are not just ensuring proper payment; you are protecting your organization’s financial health and solidifying your value as an indispensable expert in the ever-changing world of healthcare finance. Your attention to detail directly supports the accurate representation of patient complexity, which is the foundation of modern healthcare reimbursement.

Key 2025 E/M Coding and Documentation Updates to Watch

As we navigate 2025, the refinements to E/M coding are less about massive overhauls and more about precision. Payers are using sophisticated analytics to scrutinize claims, making meticulous documentation more critical than ever. Staying ahead requires a deep understanding of these evolving standards, from the nuances of Medical Decision Making (MDM) to the specifics of telehealth billing.

Evolving MDM Definitions and Clarifications

Medical Decision Making remains the cornerstone of E/M level selection, but the interpretation of its elements continues to mature. Payers are no longer accepting generic problem lists. Instead, they demand a clear narrative that justifies the complexity. Small phrasing choices have a huge impact. For example, documenting “Hypertension, stable” supports a lower level of risk than “Hypertension, poorly controlled with medication side effects, requiring new treatment plan.” The latter demonstrates a higher complexity of problems and management options. Similarly, when documenting data reviewed, avoid double-counting. Ordering a test and reviewing the results are part of a single management decision, not two separate data points. The key is to ensure the documentation accurately reflects the provider’s cognitive work. For the latest official guidance, the American Medical Association’s CPT® Evaluation and Management page is an essential resource.

Updated Time-Based Guidance

The rules for billing by time now focus exclusively on the total time spent by the provider on the date of the encounter. This includes both face-to-face and non-face-to-face activities. The challenge lies in documenting this accurately. A simple attestation statement is best practice, for example, “I spent a total of 45 minutes today caring for this patient, which included reviewing recent labs, the office visit, and documenting the care plan.” Vague statements or missing attestations are common triggers for time-based denials. Activities that count toward total time include:

  • Reviewing tests or records before seeing the patient
  • Obtaining or reviewing a separately obtained history
  • Performing the medical exam
  • Counseling the patient, family, or caregiver
  • Ordering medications, tests, or procedures
  • Communicating with other healthcare professionals (when not separately billed)
  • Documenting the visit in the electronic health record

Accurate timestamps on notes are also crucial, as auditors will cross-reference them to ensure the claimed time is plausible within the provider’s workday.

Split/Shared and Primary Care Clinician Visits

CMS has finalized its guidance on split/shared visits for 2025, and commercial payers are expected to align. The “substantive portion” of the visit, which determines the billing provider, is now defined as the professional who spent more than half of the total time for the encounter. The previous option to use one of the three MDM elements to determine the substantive portion has been eliminated by CMS. Documentation must clearly identify both providers and specify who did what, with the billing provider attesting to their substantive involvement. An effective attestation might read, “I personally performed more than half of the total time for this patient’s encounter. I have reviewed the patient’s history and exam as documented by [NPP Name] and agree with the plan.”

Prolonged Services Reporting

Prolonged service codes remain a high-risk area for audits. Best practice is to use them sparingly and with airtight documentation. For office visits, CPT code 99417 is reported for each 15-minute increment of time beyond the maximum time for the highest-level visit (e.g., 99205 or 99215). Remember, you cannot bill for prolonged services until the full 15 minutes have passed. For a level 5 established patient visit (99215), which has a time range of 40-54 minutes, you cannot add the first unit of 99417 until the total time reaches 69 minutes (54 minutes + a full 15 minutes). Your documentation must clearly detail what activities were performed during this extra time and why it was medically necessary.

Telehealth and Virtual Visit Coding

The introduction of new CPT codes for audio-only services (98980-98982) has further standardized telehealth E/M reporting, but modifier and Place of Service (POS) usage remains a significant variable. While modifier 95 (Synchronous Telemedicine Service) is common, some payers require GT, FQ, or other specific modifiers depending on the technology used. The correct POS code—typically 02 (Telehealth Provided Other than in Patient’s Home) or 10 (Telehealth Provided in Patient’s Home)—is also critical. Always verify the current policy for each major payer. A correctly coded claim with the wrong modifier or POS will be denied. This is a simple but costly mistake that can be avoided by maintaining an updated payer-specific grid.

Documentation for Care Coordination

Documenting services like interprofessional consults, care plan oversight, and remote patient monitoring requires capturing the touchpoints that happen outside a traditional visit. For an interprofessional consult, the note must show the request, the data shared, and the treating provider’s written report back to the requesting provider. For care plan oversight, documentation should include the time spent reviewing records and communicating with other professionals involved in the patient’s care. These are often under-billed because the documentation fails to capture the cumulative time and effort involved.

Common Payer Edits and Denial Triggers

Throughout 2024 and into 2025, we’ve seen a rise in automated denials based on data analytics. Payers like Cigna have implemented policies that flag providers who consistently bill higher-level E/M codes (e.g., 99214, 99215) compared to their peers for similar diagnoses. To mitigate this, ensure the diagnosis codes are specific and that the MDM documentation robustly supports the level of service. Other common triggers include missing time attestations, cloned documentation that lacks visit-specific details, and problem lists that don’t align with the assessment and plan. Proactive internal audits can help identify these patterns before they lead to payer scrutiny.

Practical Workflow Changes and Audit Checklist for 2025

Adapting to the 2025 E/M landscape means moving from theory to practice. Your first step is to refine your daily workflows. Start with the Electronic Health Record (EHR). Collaborate with your IT team or EHR administrator to update templates. Instead of generic text boxes, build structured fields or smart phrases that prompt clinicians for the specifics of Medical Decision Making (MDM). For example, a template could include distinct prompts for “Number and Complexity of Problems Addressed,” “Amount and/or Complexity of Data to be Reviewed and Analyzed,” and “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This guides providers to document what’s needed for accurate coding without suggesting a specific E/M level.

Clear communication with clinicians is more important than ever. Your goal is to reduce back-and-forth queries by improving documentation on the front end. When a query is necessary, it must be precise and non-leading. Avoid asking questions that suggest an answer. Instead, focus on clarifying ambiguity.

Here are a couple of sample queries you can adapt:

For MDM clarification:
"Dr. Smith, the documentation mentions reviewing 'outside records.' For accurate coding and to reflect the complexity of your work, could you please specify the source of these records (e.g., hospital discharge summary, specialist consult note) and summarize your findings?"

For time-based billing clarification:
"Dr. Jones, the total time documented for this encounter is 70 minutes. To ensure compliance for billing prolonged services, could you please confirm that this time includes only your personal time spent on qualifying activities on the date of the encounter and attest to this in the record?"

For split/shared encounters, documentation must clearly show the substantive portion was met by the billing provider. The attending physician’s note should explicitly state their involvement. An effective attestation might read, “I personally performed more than half of the total time for this patient’s encounter. I have reviewed the patient’s history and exam as documented by [NPP Name] and agree with the plan.” This leaves no room for auditor interpretation.

Regular internal audits are your best defense against denials and compliance risks. A focused, prioritized checklist helps you spot trends quickly. Here are the top 10 items your team should review on every E/M claim.

  1. MDM Problem Complexity
    Does the note clearly define each problem as stable, worsening, or acute and uncomplicated? Vague terms are a red flag.
  2. MDM Data Analysis
    Is there documentation of an independent historian, review of prior external notes, or ordering of tests? The simple act of ordering a test is not enough; the thought process or analysis counts.
  3. MDM Risk Assessment
    Does the documentation connect the treatment plan to the patient’s risk? For example, noting prescription drug management must be linked to the specific risks being monitored.
  4. Total Time Documentation
    If billing by time, is the total time spent by the provider on the date of service clearly stated? A simple “I spent X minutes…” is sufficient.
  5. Split/Shared Substantiation
    Does the billing provider’s documentation prove they performed more than half of the total time for the visit?
  6. Prolonged Service Thresholds
    Was the base code’s maximum time exceeded by a full 15 minutes before adding prolonged service code 99417? For a 99215, this means documenting at least 69 minutes of total time.
  7. Telehealth Modifiers and POS
    Are the correct Place of Service (POS 02 or 10) and modifiers (e.g., 95, FQ) applied based on the latest payer-specific guidelines? This remains a top area for denials.
  8. ICD-10 Linkage
    Does each diagnosis logically support the level of service billed? A high-level E/M for a simple, self-limited condition will likely be downcoded.
  9. Attestation Signatures
    Are all notes, including attestations for split/shared or teaching physician services, signed and dated by the appropriate provider?
  10. New vs. Established Patient Status
    Has the patient been seen by the provider or another provider of the same specialty in the group within the last three years? Verifying this status is a simple but often missed step.

Finally, establish a rhythm for continuous improvement. Track key performance indicators to measure your team’s success. Monitor your denial rate by payer, the average dollar amount per denial, documentation query turnaround time, and individual coder accuracy rates. Review these metrics monthly to identify problem areas. Based on these findings, schedule quarterly education refreshers for both coders and clinicians. A consistent cycle of auditing, reporting, and training will ensure your practice not only adapts to the 2025 changes but thrives.

How 2025 E/M Updates Affect Medical Coding Careers and Job Search

The constant evolution of E/M guidelines isn’t just about changing rules; it’s about reshaping the very definition of a successful medical coder or biller. As we move through 2025, the demand isn’t for simple code lookup specialists. Instead, employers are actively seeking analytical thinkers who can protect revenue and ensure compliance in a landscape defined by nuance. Thriving in this environment means mastering a specific set of high-value skills that directly address the year’s biggest changes.

The most critical skills now revolve around interpretation and investigation.

  • Deep MDM Familiarity.
    Understanding Medical Decision Making is no longer optional. It is the core competency. Employers need coders who can dissect a provider’s note, accurately weigh the number and complexity of problems, the data reviewed, and the risk of complications. This skill moves you from a data entry role to a vital part of the clinical documentation and revenue cycle team.
  • Telehealth Coding Expertise.
    With new CPT codes for audio-only services (98980-98982) now established, proficiency in applying these codes, along with the correct modifiers for audio-only versus audio-visual encounters, is essential, particularly for the growing number of remote coding positions.
  • Advanced EHR Proficiency.
    Knowing how to navigate an Electronic Health Record is standard. What sets you apart is understanding how to leverage it. This includes knowing how templates are built to capture MDM elements and time, and identifying when a template’s output doesn’t align with the provider’s narrative, preventing potential compliance issues.
  • Audit and CQI Experience.
    Coders with experience in auditing and Continuous Quality Improvement (CQI) are in high demand. The ability to perform internal audits, identify patterns of incorrect coding, and help educate providers is a powerful skill that demonstrates proactive value far beyond day-to-day coding.
  • Payer Policy Research.
    You must be a detective. With payers like Cigna implementing policies that scrutinize high-level E/M billing patterns, the ability to find, read, and apply specific payer guidelines is crucial for preventing denials. This skill shows you can adapt to a fragmented and ever-changing reimbursement environment.

While experience is key, certifications remain the gateway to getting noticed. Credentials like the Certified Professional Coder (CPC), Certified Coding Associate (CCA), Certified Professional Biller (CPB), and Certified Coding Specialist (CCS) are foundational. These certifications signal a baseline of knowledge, but it’s your specialized, up-to-date E/M expertise that will secure the best roles.

To position yourself effectively, your professional brand must scream “2025 E/M expert.” For both remote and in-office roles, update your resume with keywords like “MDM analysis,” “2025 telehealth coding,” “split/shared visit compliance,” and “denial prevention.” Go a step further by creating a small portfolio. Include a de-identified summary of an audit you performed, showing the issue, the recommended solution, and the positive outcome. If you’ve led any training, include a one-page summary or a few slides from your presentation.

During interviews, be ready to discuss the specifics. When asked about a challenge, talk about navigating a claim where MDM was ambiguous and how you formulated a compliant, non-leading query to the clinician. Discuss how you would handle a denial from a commercial payer based on their unique E/M policy. These talking points prove you aren’t just aware of the changes; you are actively applying them.

Continuous education is non-negotiable. When choosing a training program to sharpen your 2025 E/M skills, look for courses directly tied to the latest AMA and CMS guidance. The best programs are taught by instructors with real-world auditing credentials, feature practical exercises where you audit sample notes, and provide clear explanations of how to apply the rules for time, MDM, and telehealth. Avoid any program that hasn’t explicitly updated its curriculum for the CY 2025 Physician Fee Schedule.

Finally, use this expertise to negotiate your compensation and demonstrate your worth. Your value is measurable. Track your impact on the revenue cycle. Frame your contributions in terms of dollars and cents. Instead of saying “I am an accurate coder,” say “My focus on MDM documentation clarity helped reduce E/M denials from our top commercial payer by 10% in the last quarter, protecting over $50,000 in revenue.” This data-driven approach proves you are not a cost center but a strategic asset, justifying a higher salary and securing your place as an indispensable member of the healthcare team.

Common Questions and Answers About 2025 E/M Coding Changes

Navigating the day-to-day realities of E/M coding means having quick, reliable answers to the questions that pop up most often. Here are some of the most common questions we see from coders and billers about the 2025 E/M guidelines, along with straightforward, actionable answers.

What determines the E/M level now, MDM or time, and how do I choose?
For most outpatient and office E/M services, the billing provider can choose to level the visit based on either Medical Decision Making (MDM) or total time. The choice isn’t about which is easier, but which is best supported by the clinical documentation for that specific encounter. If a visit involved a complex diagnostic puzzle but didn’t take very long, MDM is the way to go. Conversely, if a visit was lengthy due to extensive counseling or care coordination for a less complex issue, time might be the better choice. The golden rule is to select the method that the documentation most clearly and robustly defends. While both are valid, the industry trend continues to lean on MDM as the primary reflection of the provider’s cognitive work.

How should I handle payer variability when one payer accepts a level and another denies it?
Payer variability is a constant. The best defense is a good offense. Maintain a detailed, up-to-date matrix of major payer policies on E/M coding. When a claim is denied, your first step is to cross-reference the chart with that specific payer’s published rules. If your coding aligns with their policy, file a well-reasoned appeal that cites their own guidelines. If the denial seems to be based on a pattern, such as consistent downcoding of level 4 visits, it’s time to analyze your documentation practices. You may need to educate providers on how to better articulate their MDM to meet that payer’s expectations. Tracking denial reasons by payer is critical for identifying these trends early.

What are the best practices for writing clinician queries without leading?
A query should be a conversation starter, not an instruction. To avoid leading, ask open-ended questions grounded in the clinical facts already in the record.

  • Instead of: “Can you add more detail to support a higher level of MDM?”
  • Try: “The assessment notes stable hypertension, but the plan includes adding a new class of medication. Could you please clarify the clinical rationale for this change to help ensure the documentation fully reflects your medical decision making?”

Using multiple-choice options can also be effective, as long as all options are clinically valid and supported by the chart. Always present the facts and ask for clarification, rather than suggesting a specific outcome.

When should a coder escalate an ambiguous E/M note to a supervisor or CDI?
Escalate a case when you’ve done your due diligence and still can’t confidently assign a code. This typically happens in a few scenarios: the documentation contains significant contradictions, a provider’s response to your query remains unclear, or the case falls into a high-risk audit category (like prolonged services) and the documentation is borderline. Your first stop is usually a senior coder or your direct supervisor. If the ambiguity is rooted in clinical details, it’s a perfect candidate for escalation to a Clinical Documentation Integrity (CDI) specialist. They are equipped to have a more clinical, peer-to-peer conversation with the provider to achieve the necessary clarity.

Conclusions and Next Steps for Growing Your Coding Career

The constant evolution of E/M coding can feel overwhelming, but the 2025 updates offer a direct route to becoming an indispensable asset to your organization. By mastering these changes, you move from being a reactive coder to a proactive revenue cycle strategist. The core principles we’ve discussed solidify this opportunity. The continued focus on Medical Decision Making (MDM) and time isn’t just a guideline change; it’s a call for higher-quality clinical documentation. Your role is to help bridge the gap between clinical practice and compliant billing, ensuring the provider’s narrative is accurately translated into the correct E/M level. This is where your expertise truly shines.

At the same time, the landscape is complicated by persistent payer variability. What one commercial payer accepts, another may deny, making a one-size-fits-all approach obsolete. This is especially true for telehealth codes and the nuanced rules for split/shared visits. A coder who can navigate these different requirements, track policy changes, and minimize denials becomes a critical team member. Success in 2025 depends less on memorizing a single set of rules and more on developing a system for managing multiple, often conflicting, guidelines. This environment rewards those who are organized, detail-oriented, and excellent communicators. Regular internal auditing and targeted education are no longer just best practices; they are essential tools for survival and growth. They allow you to identify risks before they become costly problems and to demonstrate your value through measurable improvements in coding accuracy and reimbursement.

Turning these insights into action is what separates a good coder from a great one. Instead of waiting for denials to pile up, you can take control now. Here is a practical, 4-step checklist to implement over the next 30 to 90 days to solidify your expertise and grow your career.

  1. Update Your Payer Policy Matrix.
    Within the next 30 days, create or update a spreadsheet that tracks the top five payers for your practice. Document their specific policies on telehealth modifiers, what they count toward total time, and any unique documentation requirements for high-level E/M services like 99215. This living document will become your go-to resource for preventing simple denials.
  2. Run a Focused E/M Audit.
    In the next 60 days, conduct a small, targeted audit of 10 to 15 claims for each of your most frequently billed E/M codes. Look specifically for disconnects between the documented MDM and the level billed. Are providers clearly stating the complexity of problems? Is the data reviewed properly credited? Use your findings to identify patterns and create a short, actionable report for your supervisor or practice manager.
  3. Schedule a Clinician Documentation Training Session.
    Using the data from your audit, schedule a 30-minute lunch-and-learn with your clinical team within the next 90 days. Focus on one or two key areas for improvement. Instead of just listing rules, show de-identified examples of strong and weak documentation. Frame the session as a collaborative effort to improve accuracy and protect revenue, not as a critique of their work.
  4. Enroll in a Targeted Continuing Education Course.
    Identify one area where you feel less confident, whether it’s the new audio-only telehealth codes or advanced MDM for a specific specialty. Within the next 90 days, find and enroll in a webinar or course that addresses it. Resources from the AMA, like the CPT® Evaluation and Management page, are a great place to start. Investing in your own knowledge is the most effective way to advance your career.

Embracing a mindset of proactive learning is crucial. Make it a weekly habit to check the websites and bulletins of your key payers. Join the conversation in professional communities like AAPC and AHIMA. Their forums and local chapter meetings are invaluable for real-time guidance, problem-solving, and discovering new job opportunities. The 2025 E/M updates are not just another set of rules to learn. They are a professional turning point, offering you the chance to deepen your expertise, prove your value, and build a more resilient and rewarding career.

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Informational Content Only: This article provides information regarding medical coding, billing, and compliance guidelines (specifically related to Evaluation and Management services). This content is for informational and educational purposes only and does not constitute professional legal, financial, or medical advice. Readers should consult with qualified legal counsel, financial advisors, or certified medical coding professionals regarding specific compliance issues, audit strategies, or the application of CPT, CMS, or payer rules to their individual practice or situation.

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