Inpatient and Observation Care E/M Services
Instructor
Brittany Sowards, BA, CPC, CPMA, CCC, CCVTCDescription
Inpatient and Observation Care E/M Services is a self-paced, online course designed for coders reporting hospital inpatient and observation Evaluation and Management services across professional fee and facility outpatient settings. The course reviews CPT guidelines for selecting the appropriate codes for initial and subsequent care, discharge services, same-day admission and discharge, and inpatient or observation consultations, with clear instruction on when to base code selection on medical decision making versus time. Upon completion, learners should be able to accurately distinguish inpatient versus observation status for coding purposes and apply payer-specific rules, including CMS guidance, to reduce errors related to multiple same-day visits and prolonged services.
Included Lessons:
- Inpatient and Observation Care E/M Overview
- Hospital Inpatient and Observation Care Services
- Consultations
- Level of Service
- Test Yourself
- References and Additional Content
CEUs available for the following credentials:
AAPC
COC, CPC, CPC-P, CEMC, CIC, CPB, CPPM
AHIMA
CCA, CCS, CCS-P, RHIT, RHIA, CDIP, CHDA, CHPS
Key Takeaways
Overall, this course equips coders with the knowledge and practical skills needed to accurately report inpatient and observation Evaluation and Management services, supporting compliant coding and consistent code selection across hospital-based encounters.
- Clear Understanding of Inpatient vs. Observation Status: Coders will understand how provider orders, medical necessity, and payer guidance determine patient status and drive E/M code selection.
- Accurate Use of Inpatient and Observation E/M Codes: Coders will be able to distinguish and apply initial, subsequent, discharge, same-day admission and discharge, and consultation codes in both inpatient and observation settings.
- Confidence with MDM and Time-Based Coding: Coders will learn how to select the appropriate level of service using medical decision making or total time, including when to apply prolonged services.
- Application of CPT and CMS Guidance: Coders will gain clarity on CPT guidelines, CMS-specific rules, and common payer variations that impact reporting of inpatient and observation services.
- Proper Handling of Multiple Visits and Providers: Coders will understand how same-day visits, group and specialty rules, APP services, and split or shared services affect coding.
- Reduced Risk of Common Coding Errors: Coders will leave better prepared to avoid errors related to status changes, same-day encounters, discharge reporting, and consultation coding.
Benefits of Taking this Course
- Enhances inpatient and observation E/M coding knowledge
- Improves accuracy in E/M level selection
- Strengthens application of MDM and time-based rules
- Deepens understanding of payer and CMS guidelines
- Supports professional growth in hospital-based coding
FAQs
How does this course introduce the fundamentals of inpatient and observation E/M coding?
This course walks through the core structure of inpatient and observation Evaluation and Management services, including how CPT organizes initial, subsequent, discharge, same-day admission and discharge, and consultation codes, with clear explanations tied to real hospital coding scenarios.
Does this course cover how to select E/M levels using medical decision making or time?
Yes. The course reviews medical decision making components, the MDM grid, and time-based coding rules, including what activities count toward total time and when prolonged services may be reported.
Will I learn how to code same-day admissions, discharges, and multiple visits correctly?
Yes. The course addresses common inpatient and observation scenarios such as multiple visits on the same day, same-day admission and discharge services, status changes, and how group and specialty rules affect reporting.
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.
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