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CPC STUDY COURSE · 2026 EDITION

Several passes before one adequacy assessment

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

Chart gym · Original fictional record

Service date: 2026-09-09 · Outpatient laboratory; Medicare reporting relationship

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

Sampling procedure

Fictional adult undergoes needle aspiration of one documented lesion. During sampling, material is sent promptly to the pathologist for an immediate adequacy assessment. This exercise concerns the pathology evaluation episode, not the primary aspiration procedure.

Timeline

At 10:02 the first material arrives. The clinician continues sampling while the pathologist examines it. More material from subsequent passes arrives at 10:04 and 10:06. The clinician does not pause for a communicated assessment before those passes.

Communication

At 10:08 the pathologist communicates one adequacy assessment. Sampling then ends. The record contains no later assessment-driven decision to take further material and no additional evaluation episode after the communication.

Unit proposal

The worksheet lists several needle passes and several slides. A draft assigns one immediate adequacy episode per pass. Review the episode definition and the sequence of communication rather than treating passes or slides as the coding unit.

Your coding worksheet

  1. Locate the communicated adequacy assessment.
  2. Determine whether another episode begins afterward.
  3. Evaluate units based on needle passes.
  4. Separate the pathology episode from aspiration units.

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. One assessment is communicated at 10:08.
  2. No further assessment-driven sampling occurs after it.
  3. The sequence establishes one episode under NCCI M.7, despite several passes.
  4. The primary aspiration service has a separate entry and unit review.

Reference sections: M.7

Practice the linked chart questions

Review the lesson

Sources

  1. CMS — Medicare NCCI 2026 Chapter X: Pathology and Laboratory. 2026. Accessed 2026-09-10.

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