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.