Routine cuff fixation after vaginal hysterectomy

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 professional procedure; cited Medicare NCCI relationship

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

Operative context

Fictional adult undergoes vaginal hysterectomy for a physician-documented benign uterine condition. The report identifies removal of the uterine body and cervix. No separate anterior or posterior compartment repair is performed in this exercise.

Closure details

After completing the removal, the surgeon performs the routine fixation of the vagina to surrounding tissues and closes the cuff. The full report does not document a more extensive colpopexy meeting a separate entry’s requirements. The record explicitly describes the step as routine fixation.

Scope of the exercise

This case tests the relationship of routine fixation to the hysterectomy. It does not supply all measurements needed to select a final hysterectomy code. Those would require the complete operative record and authorized entry; missing details must not be invented.

Charge review

A draft adds colpopexy solely because the surgeon uses the word fixation. Compare the actual work with NCCI’s distinction between routine fixation and the more extensive separately reportable procedure. Preserve accurate closure documentation even when it is included.

Your coding worksheet

Identify the routine step being reviewed.
State whether more extensive colpopexy is documented.
Evaluate the extra procedure line.
List the remaining full-entry checks without inventing measurements.

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 report describes routine vaginal fixation during the vaginal hysterectomy.
No more extensive colpopexy is documented.
NCCI E.10 does not allow routine fixation alone to establish the additional procedure.
The final hysterectomy entry still needs its complete operative facts; this relationship exercise does not authorize guessing missing measurements.

Reference sections: E.10

Practice the linked chart questions