History and Examination requirement for E/M services

Question:

I have been practicing for many years and am confused about the E/M guidelines since the changes were made a few years ago, mainly for my office services 99202-99215.  My coder says I should document an history and examination, but I don’t think this is required anymore.  Am I correct?

Answer:

The evaluation and management service levels are no longer determined by history and examination but are based on medical-decision making or Time except for emergency department visit codes (99281-99285), which do not contain a time component. However, a clinically relevant history and examination are required based on the practitioner’s clinical judgment. It is essential to tell the “story” of the patient’s clinical picture in the documentation. The history and examination support the medical necessity for the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical practitioners.

*This response is based on the best information available as of 1/2/25.