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September 4, 2025

Coding Guide – E/M Services


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This coding guide will describe the guidelines for evaluation and management (E/M) services reported in the office or outpatient department, consultations, ED visits, inpatient and observation hospital visits, nursing facility and home services. There are specific changes related to these categories of codes described here. The guide will also discuss how to select the level of service based on either time or medical decision-making. Not included in the guide are the rules for critical care, preventive medicine services, and prolonged visits. Medicare’s split/ shared services are also not covered in this guide. All of those topics have their own articles, guides and in some cases videos here on CodingIntel. You can find those in the site table of contents.

Table of contents

  • History and exam
  • Split/shared services
  • Using time
  • E/M and procedure of the same date of service
  • First element of MDM
  • Second element of MDM
  • Third element of MDM
  • Guideline overview
  • Types of services
  • Reference sheets: E/M services
  • Reference sheet: typical time

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Other Guides

  • How Physician Services are Paid
  • Risk Adjusted Diagnosis Coding for Medical Practices
  • Critical Care Services
  • More

Last revised May 28, 2025 - Betsy Nicoletti
Tags: E/M overview

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

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