CPT Coding: Evaluation and Management Services

Healthcare professionals who work in the billing realm of the medical industry require a fundamental understanding of the Current Procedural Terminology (CPT) manual, its structure and guidelines for applying codes to various procedures and services. The Evaluation and Management (E/M) section of the CPT is the most commonly used section for coding. E/M codes cover all diagnostic services provided by a physicians based on place of service, type of service and patient status.

In order to effectively work with these codes, healthcare professionals should understand the impact of patient history, examination, medical decision-making and other contributing factors to E/M code selection.

After completing this resource, learners will be able to:

• Explain the three components of E/M code assignment
• Analyze documentation of patient history, examination, and medical decision-making according to the level of service, and then use your knowledge to select the correct codes
• Assess contributing factors as they apply to the level of service and code selection
• Apply CMS Documentation Guidelines to assign codes to E/M services