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CPCSTUDY COURSEMy progress

CPC STUDY COURSE · 2026 EDITION

One thyroid lobe removed for a confirmed nontoxic nodule

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.

Clinical indication

Fictional patient Ellis Shaw, age 48, has one symptomatic left-thyroid nodule. The treating surgeon confirms a nontoxic single thyroid nodule; the patient has no documented hyperthyroidism, iodine-deficiency disorder or congenital thyroid condition. The operation is planned for the nodule’s local symptoms after clinical review.

Planned extent

The consent and operative plan describe left thyroid lobectomy with removal of the isthmus. The right thyroid lobe is to remain. No cervical lymph-node dissection or parathyroid excision is planned. An independent anesthesia professional supplies the general anesthetic service.

Completed operation

Through the documented neck incision, the surgeon removes the entire left thyroid lobe and the isthmus. The right lobe is preserved. The report documents identification and preservation of the relevant nerve and parathyroid structures; it does not describe their removal as separate procedures. No additional neck dissection is performed.

Final diagnosis

The pathology report describes a benign colloid nodule, and the surgeon adopts that final diagnosis. No malignancy or thyroiditis is diagnosed. Routine postoperative care is arranged. The worksheet concerns the surgeon’s completed operation and diagnosis, with the pathology professional’s separate work outside this claim.

Coding desk

The preliminary charge list calls the operation a total thyroidectomy because the entire left lobe was removed and adds a malignant diagnosis because tissue was sent to pathology. Identify the actual anatomical extent and supported diagnosis. Use the complete licensed entry, including how it handles the isthmus, instead of relying on the word entire alone.

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 confirmed nontoxic single colloid nodule supports E04.1 through the Index and Tabular route. Benign colloid nodule does not mean a diagnosed malignant neoplasm; sending tissue for examination proves neither malignancy nor a separate biopsy by the surgeon.
  2. The whole left lobe plus the isthmus was removed, while the right lobe remained. A lobectomy is anatomically different from removing both lobes. The word entire modifies the left lobe, not the whole gland.
  3. Use the licensed entry matching unilateral lobectomy and the documented isthmus work. Do not infer a total thyroidectomy, neck dissection or parathyroid excision from nearby structures being identified.
  4. Preservation of the nerve and parathyroid structures is not removal or reconstruction of those structures. The operative report must describe an actual additional procedure before such a lookup is justified.
  5. The surgeon’s diagnosis follows the adopted final finding. The separately reporting pathologist’s examination and anesthesiologist’s service belong to their own reporting roles.
  6. Document why the tempting total-thyroidectomy and malignant-diagnosis choices fail. Both arise from replacing precise chart facts with assumptions about how extensive surgery or pathology must have been.

Reference sections: ATA operation extent; E04.1; ICD outpatient diagnosis

Practice the linked chart questions

Review the lesson

Sources

  1. American Thyroid Association — Thyroid Surgery. 2026. Accessed 2026-09-10.
  2. NCI SEER — Thyroid and parathyroid glands. 2026. Accessed 2026-09-10.
  3. CDC NCHS — ICD-10-CM April1,2026 Index and Tabular XML. April1–September30,2026. Accessed 2026-09-12.
  4. CDC/NCHS and CMS — ICD-10-CM April 1 2026 Guidelines. FY2026 April. Accessed 2026-09-10.

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