December 13, 2022

New documentation and coding requirements for evaluation and management (E/M) visits coming Jan. 1

Appropriate documentation and accurate Evaluation and Management (E/M) code leveling is important for patient care, accurate billing, timely payment collection, and multiple other reasons. In 2021, the E/M coding guidelines changed for the first time since 1997. These changes included removing and adding codes as well as changing the core criteria by which an encounter is leveled to Medical Decision Making or Time. The changes only affected Office or Other Outpatient Services.

On Jan. 1, 2023, these new guidelines will be implemented across all health care settings, including hospitals, emergency departments, nursing facilities and patients’ homes. Several codes and their descriptors have been revised, consolidated, or deleted. Changes for next year cover E/M services such as hospital observation care, E/M consultations, and prolonged services. (See AMA Summary of Revisions for more details.)

The Office of Compliance & Corporate Integrity, VMG Coding, and several practitioners have helped to develop resources to help VUMC Practitioners to master E/M code leveling. These resources can be found on the OCCI website. We encourage all affected practitioners to familiarize themselves with the new regulations, and to reach out to us at or if you have any questions.