CPC STUDY COURSE · 2026 EDITION
A current plan and a copied problem list
Read an original fictional chart, identify the supported facts, and explain your coding workflow.
Chart gym · Original fictional record
Service date: 2026-09-09 · Office professional service
Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.
Synthetic encounter and reporting party
Fictional patient: Teresa Wynn, age 74. Date: September 9, 2026. Dr. Nia Cole sees the established patient in a primary care office for scheduled hypertension follow-up. This exercise reviews the problems-addressed element.
Current concern and interval history
Teresa brings home blood-pressure readings and reports taking the established medication regimen. The clinician reviews symptoms and treatment tolerance. The patient denies a current ankle complaint and does not request evaluation of the historical ankle injury.
Current examination and assessment
Office blood pressure is 136/78, pulse 70 and regular. The clinician reviews the home trend and expressly documents: hypertension is controlled at this patient’s agreed treatment goal. The exercise supplies the clinician’s assessment; the reader is not asked to determine stability independently from the numbers.
Management today
Dr. Cole reviews the current antihypertensive regimen, documents tolerance and continues the plan. Follow-up and home-record review are arranged. The clinical decision belongs to today’s hypertension management, even though the prescription regimen is continued rather than changed.
Imported history entry
The electronic history still contains an ankle injury from several years earlier, documented as healed. It is not examined, reassessed or treated today. There is no ankle-related diagnostic testing, care coordination or referral in this encounter.
Worksheet boundary
Separate current hypertension management from the copied healed-injury entry. A diagnosis appearing on the screen is not proof that it was addressed. Do not assign a complete MDM level from this problem inventory alone; data and risk need their own supported review.
Your coding worksheet
- Build the current addressed-problem inventory.
- Separate the historical injury from current management.
- Use the clinician’s status assessment rather than interpreting stability independently.
- Explain why the problem element does not determine overall MDM alone.
In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.
Compare with the worked explanation
- The record supports current evaluation and management of hypertension.
- The copied healed-injury history does not establish another addressed problem.
- The clinician’s documented assessment and plan supply the current status; the coder should not replace that assessment with an independent clinical conclusion.
- Data and risk still require review before the overall MDM level is determined.
Reference sections: Number and complexity of problems addressed
Practice the linked chart questions
Review the lesson
Sources
- American Medical Association — CPT Evaluation and Management revisions FAQs. Current 2026 page explaining E/M revisions; use current authorized book. Accessed 2026-09-10.