An arthroscopic repair becomes open

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

Chart gym · Original fictional record

Service date: 2026-09-09 · Medicare musculoskeletal professional service

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

Planned operation

A fictional adult undergoes a planned arthroscopic repair for a documented shoulder condition. The operative record identifies the right shoulder and the intended therapeutic procedure. The arthroscopy is not performed solely to decide whether any treatment is needed.

Intraoperative course

The surgeon begins the therapeutic arthroscopic work but cannot complete the repair through that approach. The surgeon converts to an open approach and completes the repair during the same encounter. The conversion and reason are documented.

Completed service

No independent procedure is performed on the opposite shoulder. The report’s initial inspection is part of the attempted therapeutic approach. It is not described as a separately necessary diagnostic study that established the decision for an otherwise unplanned open operation.

Reporting proposal

One worksheet reports both therapeutic arthroscopy and open repair. Another replaces the attempted therapeutic code with a diagnostic arthroscopy code. The learner must preserve the documented conversion rather than relabel the work to create another service.

Your coding worksheet

Identify the planned and completed approaches.
Distinguish conversion from an independent diagnostic decision.
Evaluate both proposed extra arthroscopy lines.
Use the completed operation for the licensed-entry lookup.

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 describes attempted therapeutic arthroscopy converted to completed open repair.
It does not establish the distinct diagnostic-decision circumstance.
NCCI includes the attempted arthroscopy; substituting a diagnostic label does not change the conversion.
Select the appropriate completed open procedure after checking the full site, technique and entry instructions.

Reference sections: E.3

Practice the linked chart questions