The 2021 AMA revisions dropped the element-counting model for E/M level assignment and shifted outpatient coding to time or MDM complexity. The 2026 PFS rule builds on that framework by extending it to additional code sets and clarifying inconsistent areas. Practices that retrained for 2021 are not facing a new outpatient model, but practices still grading notes by bullet points risk missing the MDM evidence that supports the code.
From Counting to Complexity
Before 2021, 99214 for an established patient required detailed history, detailed examination, and moderate complexity medical decision-making. Physicians documented organ systems and examination components in proportion to the visit level they wanted to support, producing lengthy notes with marginal clinical relevance.
The 2021 framework removed history and examination counting requirements from the outpatient code set 99202-99215. Visit level assignment now rests on total time spent on the date of service, including non-face-to-face work, or the complexity of medical decision-making across three components.
The three MDM components are: (1) number and complexity of problems addressed; (2) amount and complexity of data reviewed and ordered; and (3) risk of complications and morbidity from the condition and management options. Each maps to straightforward, low, moderate, or high. The final MDM level is set by the two lowest of the three components.
Complex problems and high-risk management can still produce a lower code when data is undocumented. The answer is not longer documentation, but naming what happened in MDM language.
Where Notes Fall Short
The common pattern is thorough clinical reasoning that does not transfer into codeable language. The physician did the work, but the note gives the coder nothing to apply to the MDM table.
In a 3-provider internal medicine group, consider an established patient with stage 3b CKD, poorly controlled type 2 diabetes, and a new complaint of lower extremity edema. The clinician independently reviewed external nephrology labs, differentiated cardiac versus renal etiology, and started a medication requiring renal dose adjustment and drug interaction monitoring. This was a 99215 encounter.
The insufficient note says, "reviewed labs, edema likely multifactorial, started spironolactone 25 mg, follow up in 4 weeks." Independent interpretation of external labs is a data element supporting moderate-to-high MDM. Drug-drug interaction monitoring ties to the risk component for high complexity. Neither is documented in a way that attaches it to MDM categories.
The fix names what happened: "independently reviewed nephrology labs, GFR trend consistent with CKD 3b progression, interpreted by this provider" and "prescription drug management required review for drug interaction and dose adjustment in CKD, assessed and adjusted accordingly." The clinical content is the same, but the MDM is codeable.
2026 PFS Updates
The 2026 PFS final rule extends the E/M framework to additional code sets that used different criteria. Hospital observation and inpatient E/M codes now follow MDM and time-based logic similar to the outpatient model, reducing split-system burden for hospitalists.
The most relevant 2026 outpatient changes are clarification of prolonged service add-on code 99417 and documentation requirements for split/shared visits. The substantive portion question now requires documentation of specific activities performed by each clinician and total combined time.
CMS also adjusted work RVUs for several office E/M codes in the 2026 PFS, continuing recalibration of cognitive services value. The direction reinforces the transition from volume-based documentation toward work-based documentation.
Time-Based Coding Practicalities
Time-based coding has been more common since 2021, particularly for complex patients where MDM documentation is difficult to complete consistently. The 2021 framework broadened total time to include record review, communication with other providers, and ordering and reviewing results on the date of service, not just face-to-face time.
"total time 50 minutes, complex visit" is insufficient. A note describing what the time included, such as record review, discussion with the patient and family, medication reconciliation, and care coordination communication, gives the coder a defensible basis.
Time-based coding is appropriate when the clinician genuinely spent the documented time on the encounter. Using time as a fallback when MDM documentation is unclear, without accurately capturing what the time involved, creates audit exposure. Specificity is not optional here.
What Has Not Changed
The four-level MDM structure has been stable since 2021. The code range 99202/99212 through 99205/99215 maps to that structure and is not changing under the 2026 rules. Practices that rebuilt coder training and templates around MDM after 2021 are not facing a reinvention cycle.
The 2026 updates extend the same framework to additional code sets and add clarifications. For a practice consistent with the 2021 model, they are primarily relevant at the margins, especially inpatient observation, split/shared visits, and prolonged services. The outpatient office E/M framework itself is not being revised again.
Automated E/M Review
Automated coding systems operating on completed notes must solve MDM classification in real time: identify which problems were addressed, whether data review language is present and what MDM category it maps to, and which management options tie to a risk level.
Arintra reads the assessment and plan section of a signed chart and proposes an E/M level from the MDM components identified. When a component is not supported, it flags which element limits the proposed level. A coder can see whether a potential 99214 is constrained to 99213 because the data component is underdocumented, then query the physician for an addendum or accept the conservative code with full visibility into why.
For a coder working at 15 notes per hour, detail work gets abbreviated. Arintra runs the same check on every note regardless of queue depth, so the MDM flag on note 47 of 60 is as reliable as the flag on note 1.
Make MDM Support Visible
Arintra reads the assessment and plan, proposes an MDM-based E/M level, and flags the component limiting it.
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