Evaluation and Management Foundations
Instructor
Brittany Sowards, BA, CPC, CPMA, CCC, CCVTCDescription
Evaluation and Management Foundations is a self-paced, online course designed for coders who need a clear starting point for accurate and compliant E/M code selection across all care settings, including outpatient, inpatient, and professional fee coding. The course explains how E/M categories and subcategories are structured in CPT, how new versus established and initial versus subsequent visit rules apply, and how to select the correct level of service using medical decision making or time. Upon completion, learners should be able to apply the MDM grid with more consistency and recognize documentation elements that support medical necessity and appropriate E/M reporting. Course duration and CEU details are listed on this page.
Included Lessons:
- Evaluation and Management Overview
- Level of Service
- Medical Decision Making - Introduction
- Medical Decision Making - Number and Complexity of Problems Addressed
- Medical Decision Making - Amount and/or Complexity of Data to be Reviewed and Analyzed
- Medical Decision Making - Risk of Complications and/or Morbidity or Mortality of Patient Management
- Medical Decision Making Case Study: Putting it All Together
- Time-Based Coding
- Test Yourself
- References and Additional Content
CEUs available for the following credentials:
AAPC
COC, CPC, CPC-P, CANPC, CCC, CCPC, CCVTC, CDEI, CDEO, CEDC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CIC, CIMC, COBGC, COPC, COSC, CPB, CPCD, CPCO, CPEDC, CPMA, CPMS, CPPM, CPRC, CRC, CRHC, CSFAC, CUC, CVBA, FMC, RCMS
AHIMA
CCA, CCS, CCS-P, RHIT, RHIA, CDIP, CHDA, CHPS
Key Takeaways
- Understanding of E/M Code Structure: Participants will gain a clear understanding of how Evaluation and Management services are organized in the CPT manual, including E/M categories and subcategories, and how place of service drives code selection.
- Proficiency in New, Established, Initial, and Subsequent Visit Coding: Coders will become confident in determining patient and visit status, including applying new versus established patient rules and distinguishing initial from subsequent services across care settings.
- Mastery of Medical Decision Making (MDM): The course equips coders with a strong working knowledge of the three MDM elements—problems addressed, data, and risk—and how to apply the MDM grid to support accurate level-of-service selection.
- Accuracy in Time-Based E/M Coding: Participants will learn how total time is calculated for E/M services, which activities may be counted or excluded, and how time thresholds affect code selection across different E/M categories.
- Application of Prolonged Services Coding: Coders will develop an understanding of CPT and CMS prolonged service codes, including when add-on codes apply and how payer-specific rules impact reporting.
- Improved Documentation Review Skills: Through detailed explanations and case-based examples, participants will strengthen their ability to analyze provider documentation, identify supported E/M elements, and ensure coding reflects medical necessity and compliant reporting.
Benefits of Taking this Course
- Foundational Evaluation and Management coding skillset
- More accurate E/M category and level selection
- Stronger application of medical decision making and time-based rules
- Improved documentation support for medical necessity
- Greater confidence with CPT and payer-specific E/M guidelines
FAQs
Will this course help clarify how E/M categories and subcategories are selected based on the care setting?
Yes. The course reviews how place of service drives E/M category selection and why subcategory rules and payer policies matter. This helps coders choose the correct code family before determining the appropriate level of service.
Does this course cover how new versus established patient status impacts E/M coding?
Yes. The course explains the three-year lookback rule for new versus established patients and how prior face-to-face services affect code selection. It also reviews how group, specialty, and subspecialty rules can change whether a patient qualifies as new.
Will this course help coders avoid common E/M errors tied to documentation and medical necessity?
Yes. The course emphasizes that the reported level must support medical necessity and highlights documentation details that demonstrate problems addressed, data review, and risk. It also explains why a problem list alone is not enough and how documentation should show evaluation or management of conditions.
About Our Medical Coding Courses
HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a flexible, online education platform designed for today’s coders. With a growing catalog of AHIMA and AAPC-approved coding courses, HIAlearn supports both beginners and experienced coders looking to build confidence, accuracy, and CEU credits.
Courses are available across various coding types including CPT, E/M, ICD-10-CM, and ICD-10-PCS, and are designed for multiple specialties including inpatient, outpatient, profee, and CDI.
To stay up to date, coders can explore our Coding Updates hub for the latest ICD-10-CM, ICD-10-PCS, CPT, and IPPS changes. HIAlearn also supports organizations with group discounts and scalable team access, promoting accuracy, compliance, and continuous professional development across departments.
Overview
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