Evaluation & Management

Overview

The Evaluation & Management (E/M) Medical Coding Course focuses on teaching students how to accurately code patient evaluation and management services provided by healthcare professionals. These services include patient consultations, hospital visits, outpatient visits, and follow-up care.
In this course, students will learn how to assign the correct E/M codes based on the level of medical decision-making, patient history, examination, and the complexity of the visit. The training is based on coding guidelines from the Current Procedural Terminology (CPT) system used in healthcare billing.
Learners will also understand how to review physician documentation, identify key components of patient encounters, and determine the appropriate level of service. Through practical examples and real-world case studies, the course helps students develop strong skills in evaluation and management coding.
This course prepares students for careers in hospitals, healthcare BPOs, insurance companies, and medical billing organizations where accurate E/M coding is essential for proper healthcare documentation and insurance claim processing.

Key Features

  • E/M Coding Fundamentals Learn the structure and guidelines of Evaluation & Management coding using Current Procedural Terminology (CPT).

  • Patient Visit Level Identification Understand how to determine the correct level of patient visits such as outpatient, inpatient, and consultation services.

  • Medical Documentation Analysis Learn how to review physician notes, patient history, and examination reports for accurate coding.

  • Practical Case Studies Hands-on practice with real-world patient scenarios and coding exercises.

  • Compliance & Billing Guidelines Understand coding rules and compliance standards used in healthcare billing and insurance claims.

Course Objectives

Job Opportunities After Completing the course

Salary Prospects – Emergency Department (ED)

Country
Average Salary
United States
$45,000 – $75,000 per year
United Kingdom
£22,000 – £40,000 per year
India
₹2 – ₹9 LPA per year
Australia
AUD 55,000 – AUD 85,000 per year
UAE
AED 3,000 – AED 12,000 per month
Singapore
SGD 2,800 – SGD 5,500 per month

Who Should Take This Course

Course Content

  • Overview of Medical Coding
  • ICD-10-CM, CPT®, HCPCS Overview
  •  US Healthcare System & Payer Types
  • Medical Documentation Standards
  • HIPAA Basics
  • What is E/M Coding?
  • Importance of E/M in Reimbursement
  • Evolution of E/M Guidelines
  • CPT Structure for E/M Codes
  • Office / Outpatient Visits
  • Inpatient & Observation Care
  • Emergency Department (ED) Visits
  • Consultations
  • Preventive Medicine Services
  • Nursing Facility & Home Services
  • History & Exam – When Required
  • Medical Decision Making (MDM) Concept
  • Time-Based Coding (When Applicable)
  • Provider Documentation Requirements
  • Number & Complexity of Problems
  • Amount & Complexity of Data
  • Risk of Complications & Morbidity
  • Low / Moderate / High MDM
  • Level Selection Rules
  • New vs Established Patients
  • Problem-Oriented Visits
  • Chronic Condition Management
  • Split / Shared Visits
    Telehealth E/M Coding
  • Initial vs Subsequent Inpatient Care
  • Observation Care Guidelines
  • ED E/M Levels (99281–99285)
  • Critical Care Overview (99291–99292)
  • When to Use Time vs MDM
  • Total Time Calculation
  • Documentation Examples
  • Prolonged Services Overview
  • Modifier -25 (E/M with Procedure)
  • Modifier -24, -57
  • Split / Shared Modifier Rules
  • Telehealth Modifiers & POS
  • Medical Necessity
  • Diagnosis Selection for E/M
  • Acute vs Chronic Conditions
  • Z-Codes Usage
  • Common E/M Coding Errors
  • Overcoding vs Undercoding Audit Triggers
  • Documentation Best Practices
  • Provider Note Review
  • MDM Level Selection Exercises
  • Time-Based Coding Scenarios
  • Denial Correction Practice
  • Mock Charts