Gedeelde audio

Beginning in 2021, the guidelines for documenting E/M codes for office or other outpatient visits have been simplified, requiring a patient history and/or exam containing only information that is medically relevant for the physician. What is considered medically relevant will depend on the reason for the encounter. The final E/M code selection is then determined by either medical decision-making (MDM) or total physician time on the date of the encounter.