E/M 2026 Updates: What Changed for Medicare E/M Coding

Part 2 of 9

Where Medicare and CPT disagree

These numbers cause the most claim errors. The AMA (CPT) counts the extra 15 minutes from the code's minimum time: 99205 is 60 minutes, so 99417 starts at 75. The AMA removed the time ranges in 2024, but CMS did not change G2212. Medicare still counts from the top of the old range: 74 minutes for 99205 and 54 for 99215. So G2212 starts at 89 and 69 minutes (MLN006764 Table 3; manual §30.6.15.2).

Situation	CPT / most other payers	Medicare (2026)
Office prolonged time, new patient	99205 + 99417 from 75 min	99205 + G2212 from 89 min
Office prolonged time, established	99215 + 99417 from 55 min	99215 + G2212 from 69 min
Critical care, first add-on unit	99291 + 99292 from 75 min	99291 + 99292 from 104 min
Consultation	99242–99245, 99252–99255	Not paid: bill the office, hospital or NF visit code
Prolonged hospital, NF, home	99418 / 99417	G0316 / G0317 / G0318

Corrected on this site

When we checked our lessons against the May 2026 booklet and manual, we found and fixed these errors:

Prolonged Services and How E/M Evolved said Medicare pays 99205 + G2212 at 75 minutes from 2024. Medicare still needs 89 minutes (Table 3; manual §30.6.15.2).
Critical Care said only one doctor can bill critical care per day for Medicare. Since 2022, different specialties can each bill, and same-specialty, same-group practitioners share one 99291 (§30.6.12.3–4). Its time table and the five critical care practice reports now show the Medicare 104-minute rule beside CPT's.
Same Day Admit & Discharge said an admission with a less-than-comprehensive H&P must be 99221. Since 2023, history and exam don't set the level.
E/M FAQs said NPPs can't bill admissions and discharges on their own. Medicare pays them when the service is within their scope of practice.

Done: Medicare vs CPT

Part 3 of 9

1. G2211: visit complexity add-on

G2211 pays for the ongoing relationship, not for a complicated diagnosis. Report it when you are the continuing focal point for all of the patient's care (primary care), or when you give ongoing care for a single serious or complex condition (HIV, sickle cell disease).

Base codes: office/outpatient 99202–99205, 99211–99215 and, from 1 January 2026, home or residence 99341, 99342, 99344, 99345, 99347–99350.
Modifier 25: not paid when the base visit carries modifier 25, except when the other same-day service is an AWV/IPPE, vaccine administration or a Part B preventive service.
Any specialty can bill it. Document why the visit was needed and the ongoing relationship.

Claim A

Home visit, 2026

99349established patient, moderate MDMPaid
G2211PCP who manages all her carePaid

From 2026, the PCP who is the focal point for a homebound patient's care can add G2211 to a home visit.

Claim B

Office visit with a joint injection

99213-25Paid
20610Paid
G2211modifier 25 with a procedureDenied

Modifier 25 is for a same-day procedure, not a preventive service, so Medicare does not pay G2211.

No, because modifier 25 is usedYes: 99213-25 + G2211Only G2211, without 99213

2. G0136: now a physical activity and nutrition assessment

From 2026, G0136 is no longer the social determinants of health (SDOH) risk assessment. It is now the physical activity and nutrition risk assessment. It can be done during an E/M visit, an AWV or a behavioral health office visit.

Done: G2211 and G0136

Part 4 of 9

3. Prolonged services

Prolonged codes are reported only when time was used to pick the visit level, and only with the highest code of the family. Each unit needs a full 15 minutes past the threshold.

Primary service	Medicare code	First unit at (total time)	Count time in this window
99205 office, new	G2212	89 min	Date of visit
99215 office, established	G2212	69 min	Date of visit
99223 initial hospital/obs	G0316	90 min	Date of visit
99233 subsequent hospital/obs	G0316	65 min	Date of visit
99236 same-day admit/discharge	G0316	110 min	Date of visit to 3 days after
99306 initial NF	G0317	95 min	1 day before + date + 3 days after
99310 subsequent NF	G0317	85 min	1 day before + date + 3 days after
99345 home, new	G0318	140 min	3 days before + date + 7 days after
99350 home, established	G0318	110 min	3 days before + date + 7 days after
99483 cognitive assessment	G2212	100 min	3 days before + date + 7 days after

Not with: ED visits, critical care, discharge day management (99238–99239, 99315–99316) or consultations. G2212 is not reported on the same date as 99358, 99359, 99415 or 99416.

CASE 01

Established office patient, 100 minutes

A Medicare patient with uncontrolled diabetes, CKD and new edema. The physician documents 100 minutes of total time on the date of service, including reviewing outside records and calling the nephrologist. The level is chosen by time.

Reveal answer & rationale

Medicare: 99215 + G2212 ×3. The first G2212 is at 69 minutes, the second at 84 and the third at 99. 100 minutes reaches the third unit. (CPT: 99215 + 99417 ×4, counted from 55 minutes.)

Full lesson: Prolonged Services.

Done: Prolonged services

Part 5 of 9

4. Critical care

99291 covers 30–74 minutes, once per date per patient, even if the time is not continuous.
99292 (Medicare) needs 104 total minutes (74 + 30), then each further full 30 minutes.
Different specialties can each bill critical care on the same date if it isn't duplicative. Practitioners of the same specialty and group add their time together and report only one 99291.
Same-day E/M first, then critical care: bill both, with modifier 25 on the E/M, when the E/M came first, was needed, and doesn't overlap.
Global surgery: critical care unrelated to the surgery (for example trauma or burns) is paid with modifier FT. An intensivist who takes over the postoperative care reports 55 + FT, and the surgeon reports 54.

CASE 02

Two intensivists, one day

Dr. A (pulmonary critical care) spends 50 minutes stabilizing a patient in septic shock in the morning. Dr. B, from the same group and specialty, spends 70 minutes in the evening when the patient deteriorates. Payer: Medicare.

Reveal answer & rationale

99291 ×1 + 99292 ×1 under one of them. Same specialty and group, so the time is added: 50 + 70 = 120 minutes. 99291 covers the first 74 minutes, and 104 minutes reaches one 99292. Two units would need 134 minutes.

Full lesson: Critical Care.

Done: Critical care

Part 6 of 9

5. Split (or shared) visits

A visit in a facility setting (hospital, ED, SNF) done partly by a physician and partly by an NPP of the same group. The practitioner who does the substantive portion bills, with modifier FS.

Family	Substantive portion
Hospital inpatient, observation, outpatient hospital, SNF	More than half the total time or a substantive part of the MDM
ED	More than half the total time or a substantive part of the MDM
Critical care	More than half the total time only
Office, nursing facility	Not allowed (incident-to rules apply)

Count only distinct time. Joint time counts once.
One of the two must see the patient in person. It doesn't have to be the one who bills.
The billing practitioner signs and dates the record, and the record identifies both.
Modifier 52 can't be used for a partial visit.

Full lesson: GC, GE & FS Modifiers.

6. Hospital inpatient and observation stays

Stay	Discharged the same calendar date	Discharged on a later date
Under 8 hours	99221–99223 only	99221–99223 only
8 hours or more	99234–99236	99221–99223 + 99238/99239

One visit per calendar date per practitioner (or same specialty and group), even for unrelated problems.
A service that runs continuously past midnight is reported on the date it began.
Moving from observation to inpatient is not a new stay.
Only the treating practitioner bills the observation codes. Others who see the patient in observation bill office/outpatient codes.
Office visit one day, admission the next: both are paid, even if less than 24 hours apart.

Observation, then admission

Medicare

Date	Provider	Documented
Mar 3, 22:00	Dr. Rao (hospitalist)	Places patient in observation for chest pain; works until 00:40
Mar 4	Dr. Rao	Converts to inpatient; progress note
Mar 4	Dr. Iyer (cardiology)	Consult requested while in observation, before admission
Mar 6	Dr. Rao	Discharge, 35 minutes

Full lessons: Hospital & Observation · Same Day Admit & Discharge.

Done: Split/shared and hospital stays

Part 7 of 9

7. Home or residence visits

One code family, 99341–99350, covers the home (POS 12), assisted living (13), group home (14), custodial care facility (33) and residential substance abuse treatment facility (55). The patient doesn't have to be homebound. With POS 12 the physician must actually be in the home. New in 2026: G2211 can be added. Prolonged time uses G0318.

Full lesson: Home or Residence Services.

8. Other rules in the booklet

Consultations: Medicare doesn't pay 99242–99245 or 99252–99255. Bill the visit code for the setting. Telehealth consults use G0406–G0408 and G0425–G0427. See Consultation.
Hospital outpatient clinic (G0463): the facility's visit code. Off-campus departments add PN (non-excepted, opened on or after 2 November 2015) or PO (excepted).
Chronic pain management: G3002 is a monthly bundle that needs an initial 30-minute face-to-face visit and at least 30 minutes a month. G3003 adds each further 15 minutes. See CCM.
Nursing facility: an initial NF visit and an office or ED visit on the same date can't both be billed.
Teaching physicians: under the primary care exception, the level is chosen by MDM only. When time is used, count only the time the teaching physician was present. See GC, GE & FS.
New patient: no professional services from the same physician, or the same specialty in the same group, within 3 years. A test interpretation alone (an EKG read, for example) doesn't make the patient established.

Done: Home visits and other rules

Part 8 of 9

Calculators

These calculators apply the Medicare rules above. Enter your own case and compare it with the examples.

E/M toolkit

Medicare rules, 2026

Primary service (highest level, chosen by time)Total practitioner time (minutes)Count time in the surveyed window: date of the visit.

Medicare

99215 ×1G2212 ×1

G2212 starts at 69 minutes, then one more unit for each further full 15 minutes. Next unit at 84 minutes.

Other payers (CPT)

99215 ×199417 ×2

CPT counts 99417 from the base code's time: the first unit at 55 minutes.

Done: Calculators

Part 9 of 9

Quick self-check

QUESTION 1

A hospitalist and an NP from the same group see an inpatient. The NP spends 25 minutes and the hospitalist 15; the hospitalist made the key management decisions (substantive part of MDM). Who can bill?

aOnly the NP, because of timebEither: the NP by time, or the hospitalist by MDMcNeither: split/shared needs equal time

QUESTION 2

A Medicare patient is in observation from 08:00 to 15:00 and discharged the same day. What does the physician bill?

a99234–99236b99221–99223 onlyc99221–99223 + 99238

QUESTION 3

Total critical care time on one date is 100 minutes (one physician, Medicare). What is billed?

a99291 ×1b99291 + 99292 ×1c99291 ×2

Where each rule is covered on this site

Topic	Lesson	What was added or corrected
G2211	G2211 Visit Complexity (new)	Base codes, 2026 home extension, modifier 25 exception, CMS examples, calculator
Home visits	Home or Residence (new)	POS 12/13/14/33/55, levels, G0318 time window, G2211
Prolonged	Prolonged Services	Corrected G2212 thresholds, Tables 3–4, calculator
Critical care	Critical Care	Medicare 104-minute rule, concurrent care, FS, FT, calculator
Split/shared, teaching	GC, GE & FS	Substantive portion by family, NF vs SNF, teaching physician rules, calculator
Hospital & obs	Hospital & Observation	Per-date rule, midnight, observation billing, drill
Short stays	Same Day Admit & Discharge	8-hour table calculator, H&P correction
Office visits	Office & Outpatient	G2211, G2212, modifier 25, 99211 + injection, G0463 PN/PO
Consultations	Consultation	Telehealth consult G-codes, observation consults, 99499
AWV	Annual Wellness Visits	AWV + problem visit + G2211, G0136 change
Place of service	Place of Service	Home and nursing facility POS table
Chronic pain	CCM	G3002/G3003 requirements
FAQs	E/M FAQs	5 new 2026 questions, NPP answer corrected
Practice	E/M 2026 practice test	12 new questions

Done: Self-check and next steps

What's New in E/M for 2026

The 2026 changes at a glance

Mind map: Medicare E/M in 2026