Evaluation & Management Coding in CPT

I.     Course Prefix/Number: HIT 120

       Course Name: Evaluation & Management Coding in CPT

       Credits: 1 (1 lecture; 0 lab)

II.    Prerequisite

HIT 170 with minimum grades of C, or consent of instructor. Recommended: Hands-on experience with word processing in Windows, or equivalent coursework.

III.   Course (Catalog) Description

Course presents in-depth study of the Evaluation and Management section of CPT coding system. Based on knowledge of key definitions required in Evaluation and Management coding. Focus on auditing documentation and validating code selection. Includes discussion of categories of service, modifier usage, and payment methodologies.

IV.   Learning Objectives

Upon successful completion of the course, the student will be able to:

  1. Understand and apply the commonly used definitions in the Evaluation and Management section of CPT to encounter documentation.
  2. Display a detailed understanding of how the seven components of an Evaluation and Management service determine code selection.
  3. Apply the criteria necessary to select a code from each of the Evaluation and Management categories.
    1. Office and outpatient visits
    2. Observation services
    3. Hospital inpatient services
    4. Consultations
    5. Emergency department  services
    6. Critical care services
    7. Neonatal intensive care
    8. Nursing facility services
    9. Prolonged services
    10. Case management and care plan oversight services
    11. Preventive medicine services
  4. Analyze various tools that exist for auditing E&M documentation.
  5. Compare and contrast the CMS documentation guidelines currently in use.
    1. 1995 guidelines
    2. 1997 guidelines
  6. Using the key components, “level” encounters using the approved documentation guidelines.
  7. Determine appropriate use of modifiers for Evaluation and Management codes.
  8. Discuss current payment methodologies for E&M services.

V.    Academic Integrity and Student Conduct

Students and employees at Oakton Community College are required to demonstrate academic integrity and follow Oakton's Code of Academic Conduct. This code prohibits:

• cheating,
• plagiarism (turning in work not written by you, or lacking proper citation),
• falsification and fabrication (lying or distorting the truth),
• helping others to cheat,
• unauthorized changes on official documents,
• pretending to be someone else or having someone else pretend to be you,
• making or accepting bribes, special favors, or threats, and
• any other behavior that violates academic integrity.

There are serious consequences to violations of the academic integrity policy. Oakton's policies and procedures provide students a fair hearing if a complaint is made against you. If you are found to have violated the policy, the minimum penalty is failure on the assignment and, a disciplinary record will be established and kept on file in the office of the Vice President for Student Affairs for a period of 3 years.

Please review the Code of Academic Conduct and the Code of Student Conduct, both located online at

VI.   Sequence of Topics

  1. Introduction to the course
  2. 1995 and 1997 documentation guidelines
  3. Elements of the history, physical exam, and decision making
  4. Auditing cases for presence of key components
  5. Contributing components of E&M coding
  6. Categories of E&M services
  7. E&M modifier usage
  8. Reimbursement issues

VII.  Methods of Instruction

Coding guidelines and instructions will be presented in lecture format for each of the topics in the course.  In-class exercises will be utilized to practice and build coding skills.  Class discussions of student’s code selection on various assignments will help develop confidence and demonstrate correct application of coding principles.

Course may be taught as face-to-face, hybrid or online course.

VIII. Course Practices Required

Students will be expected to prepare for each class by completing assigned readings and homework assignments.  Participation in class discussions will help both student and professor to assess understanding of course material.  All assignments must be submitted on due dates provided by the instructor, and should be neat and legible.

Course may be taught as face-to-face, hybrid or online course.

IX.   Instructional Materials

Note: Current textbook information for each course and section is available on Oakton's Schedule of Classes.

Students will need a current edition of a CPT Code Book.

Handouts supplied by instructor.

X.    Methods of Evaluating Student Progress

Students will be evaluated on homework assignments, and exams. Grades will be determined on a cumulative point basis, which will be averaged. Grade distribution is as follows:

Grade distribution is as follows:
A = 94%
B = 88%
C = 82%
D = 76%
F = Below 76%

XI.   Other Course Information

Health Status Change: Any change in health status of currently enrolled students, resulting in the inability to meet the course/program objectives and standards as outlined in the Essential Skills requirement policy will require documentation and medical approval for the student to return to clinical, theory, and lab – which require lifting without restrictions.

Attendance:  Class attendance is expected.  Absences should be reported to the instructor before the start of class, or as soon as possible in the case of an emergency.  It is the student's responsibility to arrange to make up the work and to find out what assignments were given.

Code of Student Conduct:  Refer to college catalog.

Make-up of Exams - Make-up of exams will be allowed when students contact the instructor prior to the exam being given.  Students will have one week from the date of the exam.  Exams will be made up in the testing center unless other arrangements are made with the instructor.

Incomplete grades - It is the student's responsibility to initiate requests for an “incomplete” and to follow through with the procedure to remove the incomplete grade.

Late assignments - Late assignments will be accepted if the student has made arrangements with the instructor prior to the due date.

If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.

Oakton Community College is committed to maintaining a campus environment emphasizing the dignity and worth of all members of the community, and complies with all federal and state Title IX requirements.

Resources and support for
  • pregnancy-related and parenting accommodations; and
  • victims of sexual misconduct
can be found at www.oakton.edu/title9/.

Resources and support for LGBTQ+ students can be found at www.oakton.edu/lgbtq.

Electronic video and/or audio recording is not permitted during class unless the student obtains written permission from the instructor. In cases where recordings are allowed, such content is restricted to personal use only. Any distribution of such recordings is strictly prohibited. Personal use is defined as use by an individual student for the purpose of studying or completing course assignments.

For students who have been approved for audio and/or video recording of lectures and other classroom activities as a reasonable accommodation by Oakton’s Access Disabilities Resource Center (ADRC), applicable federal law requires instructors to permit those recordings. Such recordings are also limited to personal use. Any distribution of such recordings is strictly prohibited.

Violation of this policy will result in disciplinary action through the Code of Student Conduct.