Abstract

Major revisions for commonly reported office and outpatient evaluation and management (E/M) codes were implemented on January 1, 2021, by the American Medical Association and Centers for Medicare and Medicaid Services. The goal of these changes was to simplify and streamline these service codes, with time and medical decision-making (MDM) now being the sole determinants of the overall E/M level. We present an overview of the new guidelines, requirements, and code descriptors to aid in accurate documentation and billing. Additional resources are provided if further billing and coding questions arise.

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