The evolution of Evaluation and Management coding didn't end with the landmark 2021 changes. CMS has continued refining E/M rules, and 2026 introduces updates that affect how practices select visit levels, document telehealth services, and bill for services that blur the line between in-person and remote care.
For most practices, E/M codes represent the single highest volume billing category. Even small improvements in accuracy — moving from level 3 to appropriate level 4 billing, or correctly capturing time-based services — have outsized revenue impact. Similarly, errors in E/M coding are the highest-dollar audit target for CMS, OIG, and commercial payers.
MDM vs. Total Time — Choosing Your Strategy
Since 2021, practices have had two pathways for selecting E/M levels: Medical Decision Making (MDM) and Total Time. The 2026 updates clarify documentation expectations for both, but the fundamental choice remains strategic.
Total time billing is often the better choice for complex patients with straightforward problems — where the physician spends significant time on coordination, ordering, and review, but the MDM elements don't clearly support a high level. If your physician spends 45 minutes on a patient and documents that time, you can bill a 99215. Under MDM, that same visit might only support a 99214 if the problems and decisions documented don't meet the higher threshold.
MDM billing is often better for patients with genuinely complex medical situations where the problems, data reviewed, and risk of complications are high, regardless of how much time was spent. A 20-minute visit for a patient with uncontrolled diabetes and a new cardiac finding can support a 99215 under MDM.
2026 E/M Documentation Expectations
The 2026 clarifications most relevant to daily practice involve MDM documentation for "new or worsening" chronic conditions. CMS has indicated that simply listing a chronic condition in the assessment doesn't make it "addressed" for MDM purposes. The note must reflect active management — a change in treatment, an order, a discussion with the patient about their status, or a decision not to change treatment with documented reasoning.
This distinction matters because practices that list chronic conditions in every visit note without active management documentation may be overcoding the number of chronic conditions addressed, which inflates MDM complexity scores beyond what the documentation supports.
Telehealth: What's Permanent in 2026
The single most important telehealth development for 2026 is the finalization of permanent coverage for a core set of telehealth services. After years of COVID waivers with annual renewal anxiety, CMS has made permanent the telehealth coverage for office visits (99202-99215), mental health services, diabetes self-management, and several other high-volume categories.
Practices can now invest in telehealth infrastructure with confidence that these services will continue to be covered. The annual uncertainty that made some practices hesitant to build telehealth programs has been resolved for the permanent code categories.
Audio-Only Telehealth — Know the Restrictions
Audio-only telehealth (phone visits without video) remains covered in 2026 but with important restrictions. The patient must be unable to use video technology due to cognitive, functional, or access limitations — not simply because it's more convenient. Documentation must reflect why audio-only was medically appropriate for that patient.
Practices that have been routinely billing audio-only telehealth without documenting the clinical justification for why video wasn't used are exposed. Auditors are looking at audio-only billing patterns, and claims that lack medical justification for the modality are subject to recoupment.
Telehealth and E/M Level Selection
A common misconception is that telehealth visits must be billed at lower levels than comparable in-person visits. This is false. A telehealth visit billed using 99214 or 99215 requires the same documentation as an in-person visit at those levels. The modality doesn't change the E/M level criteria — MDM complexity and total time apply equally.
If your practice has been systematically billing telehealth visits at lower levels than comparable in-person encounters, you're underbilling. Audit your telehealth claims against your in-person claims for the same provider and patient complexity — if there's a consistent level gap, you have a training and documentation problem worth fixing.
