The majority of E/M services are based on which of the following criteria?

In outpatient CDI and coding education, selecting the correct E/M code starts with identifying theencounter category(e.g., office/outpatient vs inpatient/observation vs ED) and whether the patient isnew or established, because these define the applicable CPT code range. Next, thelevel of serviceis selected within that range based on the documentation supporting the required elements for that code family. For most E/M services, “site of service” (place/setting) and “new vs established” are foundational code-selection drivers, while “level” is determined by the record’s support for the applicable leveling methodology (commonly medical decision making and, when allowed/appropriate, time). Time can be a valid leveling method for many office/outpatient E/M visits, but it is not universally the basis for the majority of E/M services across all categories; it is an alternative pathway when documentation supports it. Physician specialty and patient age do not define the majority of E/M code selection. Therefore, the best overall statement is new/established status + site of service + level of service.