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CPCSTUDY COURSEMy progress

CPC STUDY COURSE · 2026 EDITION

Right-eye cataract surgery and included local anesthesia

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-08 · Professional outpatient claim; Original Medicare unless stated otherwise

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Preoperative diagnosis

Fictional patient Arden Wells, age 74, has a visually significant age-related nuclear cataract in the right eye. The ophthalmologist confirms that diagnosis after evaluation and documents its effect on daily visual tasks. This packet contains no traumatic, drug-induced or congenital cataract diagnosis and no left-eye procedure for this date.

Scheduled work

The surgeon plans right-eye cataract extraction by phacoemulsification with insertion of an intraocular lens. The record identifies the right eye during the safety check. The surgeon administers local ocular anesthesia for this operation. No independent anesthesia professional’s claim is part of this worksheet.

Completed operation

The surgeon removes the right cataract by the documented phacoemulsification technique and places the planned lens. The completed report describes a routine course without the additional devices or techniques needed for the complex-entry pathway. No glaucoma procedure, separate retinal operation or second cataract-extraction technique is performed.

Completion and future plan

The surgeon confirms the lens position and gives routine postoperative instructions. A later appointment may evaluate the other eye, but no left-eye surgery occurs today. There is no separate unrelated evaluation documented during this operative encounter. The final diagnosis remains the right age-related nuclear cataract.

Charge review

The proposed surgeon claim reports cataract extraction twice under two technique entries, separately bills the surgeon’s local ocular anesthetic injection, and appends a bilateral modifier because another-eye visit is planned. Use the completed operative note to select one supported licensed procedure entry and review each extra item.

Your coding worksheet

  1. Identify the reason for this encounter and the supported diagnoses.
  2. List the services actually completed and the applicable code sets.
  3. Use your books to select final codes, units and any supported modifiers.
  4. Sequence the diagnoses and explain the relevant instruction.
  5. Review included work and any separate coverage question. Explain why the strongest alternative does not fit.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Write your answer

Use only this fictional record. Your entries stay on this page and disappear when you leave or reload. Do not enter real patient information.

Compare with the worked explanation
  1. The supported diagnosis is H25.11, verified through the age-related nuclear cataract branch for the right eye. Do not replace the documented type and side with an unspecified or bilateral assumption.
  2. Find the single licensed cataract procedure entry matching the completed phacoemulsification and lens insertion. The record excludes the extra work needed for a complex pathway; a patient’s age alone does not supply that work.
  3. NCCI VIII D.3 treats cataract extraction entries as mutually exclusive for the same eye in this relationship. Two labels on a charge sheet do not establish two independently completed extractions.
  4. The operating physician’s local anesthesia is included. NCCI VIII D.11 specifically bars separate ophthalmic injection reporting when the injected substance is anesthetic for the operation.
  5. Only the right eye was treated. Apply the appropriate current anatomical reporting instructions; do not report bilateral surgery from a future plan for the opposite eye.
  6. The routine operative assessment and postoperative instructions are not evidence of an unrelated E/M service. Any separately supported service would require its own actual documentation and rule review.

Reference sections: H25.11; NCCI VIII D.3,D.11

Practice the linked chart questions

Review the lesson

Sources

  1. CDC NCHS — ICD-10-CM April1,2026 Index and Tabular XML. April1–September30,2026. Accessed 2026-09-12.
  2. CDC/NCHS and CMS — ICD-10-CM April 1 2026 Guidelines. FY2026 April. Accessed 2026-09-10.
  3. CMS — Medicare NCCI 2026 Chapter VIII: Nervous, Eye and Auditory Systems. 2026. Accessed 2026-09-10.

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