One removal and a separate lesion sample

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 integumentary professional service

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

Encounter map

A fictional adult attends a dermatology office for two distinct concerns. Lesion A is on the left upper arm; Lesion B is on the right shoulder. The clinician separately labels both locations in the examination and procedure note.

Lesion A procedure

The clinician performs definitive removal of Lesion A. A small sample obtained from that same lesion during the removal is submitted with the removed tissue. The final entry requires the complete documented technique and applicable measurement, which the learner should locate in the full procedure record.

Lesion B procedure

The clinician obtains a diagnostic sample from the separate right-shoulder lesion. No definitive removal of Lesion B is performed in this encounter. The specimen label identifies the right shoulder and is distinct from the left-arm specimen.

Reporting review

The proposed claim has a removal line and two biopsy lines: one for tissue from Lesion A and one for Lesion B. The exercise asks which biopsy relationship supports further separate-reporting review. It does not assume that specimen labels alone satisfy every code or edit requirement.

Your coding worksheet

Map each proposed line to its lesion.
Identify tissue sampling already included in removal.
Identify the distinct biopsy that needs its own lookup.
List the technique and edit checks still required before final reporting.

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 left-arm sample belongs to Lesion A, the definitively removed lesion. The right-shoulder sample belongs to Lesion B.
Same-lesion sampling during removal is included under NCCI.
The different right-shoulder lesion supports investigating separate biopsy reporting.
Verify the biopsy technique, primary/add-on instructions and applicable edit/modifier requirements. Distinct location supports the relationship but does not replace all remaining checks.

Reference sections: E.1–2

Practice the linked chart questions