A new complaint in an established relationship

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 office professional service

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

Synthetic encounter and reporting party

Fictional patient: Marion Hale, age 72. Date: September 9, 2026. Dr. Lena Avery, family medicine, provides a professional office encounter billed to Original Medicare. This record is an educational abstraction exercise; no real patient information is used.

Reason for visit and history

Marion reports five days of right shoulder discomfort after carrying gardening supplies. The discomfort occurs with reaching overhead. No fall, direct blow, open wound, fever, hand numbness or new chest symptoms are reported. The patient has not been treated elsewhere for this episode.

Verified prior services

The practice reconciles the patient identity and historical record. On March 9, 2025, Dr. Avery personally performed a face-to-face skin biopsy at this practice. That was a clinical procedure encounter, not an interpretation-only claim. The current registration is new because insurance information was updated; the practitioner relationship has not changed.

Current examination

The note records blood pressure 126/74, pulse 72 and temperature 36.7 °C. The patient is comfortable at rest. Active overhead movement produces shoulder discomfort. There is no visible swelling or deformity, and distal motor and sensory examination is documented as intact.

Assessment and plan

Dr. Avery documents right shoulder pain without an established fracture, tendon tear or other structural diagnosis. The clinician discusses activity modification and follow-up if symptoms do not improve, with earlier reassessment for worsening or new symptoms. No separate procedure is performed today. These are facts of the fictional record, not treatment instructions for the reader.

Abstraction boundary

The requested decision is the professional service family and patient status. The supplied record does not include a complete classification of all MDM elements or a documented eligible total time. Do not invent a final service level or a more specific shoulder diagnosis.

Your coding worksheet

Identify the professional E/M family.
Use the actual prior-service date to determine status under the stated Medicare rule.
Abstract the supported diagnosis without inventing a structural injury.
State what additional detail is required before choosing the final E/M level.

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 encounter is a problem-oriented office professional service.
The qualifying face-to-face service eighteen months earlier makes the patient established under the stated Medicare definition; a new complaint or insurance record does not change that fact.
The supported symptom can be investigated in ICD-10-CM; the record does not establish a tear or fracture.
Family and status do not finish level selection. Obtain the supported MDM or permitted time evidence and verify the current entry.

Reference sections: CMS Claims Processing Manual 12, 30.6.7.A; ICD-10-CM Guidelines IV.H for the symptom-only diagnosis boundary

Practice the linked chart questions