Office Based Coding 101: It's a No Brainer

Publication ID Published Volume
8438 July 19, 2011 7


This comprehensive training program is designed to introduce and enhance Evaluation and Management coding skills for the office setting. The use of color, imagery and small group learning aid retention of the information presented. The program stresses level of service code selection based on Medical Decision Making. A unique color coded audit form is used to maximize the visual learning experience. A PowerPoint presentation and 12 weekly maintenance-of-skills scenarios are additional teaching methods. The workshop is designed to be completed in 90 minutes. Learners are asked to complete a pre-intervention skills survey. On the day of the workshop they complete a pre-intervention evaluation and a 10 item pretest. They are then divided into groups of five and given several copies of the color coded audit sheet to be used during the presentation and discussion. The PowerPoint slides aid in describing of the necessity to code properly and the elements that comprise the 99212-99215 and 99202-99205 levels of service. Interspersed are pre-test questions. Groups are asked to discuss the level of service designation and reach consensus for each case scenario as they appear in the presentation. At the conclusion a 10 item posttest is administered and participants are asked to complete a program evaluation. Following the workshop learners receive a weekly maintenance of skills scenario by email. Evaluation is based on posttest performance.

This coding workshop was developed as part of a Master’s in Academic Medicine degree requirement. The workshop was presented in the Fall of 2008 to a group of Family Medicine residents. Pre and posttest assessments were made around the workshop and at the end of 12 weeks. No significant improvement in ability to choose correct level of service was detected for the group but participation was low despite incentives. Those individuals that participated in the maintenance of skills segment regularly showed statistical improvement in post-post test scores. The color coded audit sheet is the product of over 10 years of modifications by all the authors. It is a wonderful tool for teaching and auditing charts.


Miller D, Clark K, Whitecar P, Hawkins J. Office based coding 101: it's a no brainer. MedEdPORTAL Publications. 2011;7:8438.

Educational Objectives

  1. To understand the need for CPT coding knowledge.
  2. To understand the process of CPT coding in the office.
  3. To apply CPT office based coding principles using example cases.
  4. To explain CPT level of service selected for case scenarios.
  5. To value CPT coding skills.


  • Coding, CPT, Evaluation and Management, Charts, Current Procedural Terminology

Prior Scholarly Dissemination


  1. Miller, DE. “An Innovative CPT Coding Intervention to Promote Learning and Retention of Skills”, Innovations in Medical Education, University of Southern California, Keck School of Medicine, Pasadena, California, 3/2009.

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