One fibroid, attempted ablation, completed removal

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 plan

Synthetic operative record, September 9, 2026. An adult has one symptomatic 4 cm intramural uterine leiomyoma in the anterior wall. Laparoscopic radiofrequency ablation of that fibroid is planned. No other fibroid is treated.

Signed procedure sequence

The surgeon begins laparoscopic radiofrequency ablation but cannot maintain the probe position needed to complete the planned treatment. The surgeon stops the ablation attempt and proceeds to laparoscopic myomectomy of that same fibroid during the same encounter.

Completed procedure

The single anterior-wall fibroid is enucleated, the uterine defect is sutured and hemostasis is confirmed. The fibroid specimen is submitted for pathology. The uterus is preserved, and no separate fibroid or other target is treated.

Procedure worksheet

A draft lists both the attempted radiofrequency ablation and completed laparoscopic myomectomy. Review the same-fibroid conversion rule under Medicare NCCI. Use the supplied single lesion, size, intramural location and completed technique for the authorized-book lookup.

Your coding worksheet

Identify the completed treatment.
Confirm whether one or several fibroids are involved.
Evaluate both proposed procedure lines.
Preserve the reason for the changed method.

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

Laparoscopic myomectomy completes the treatment.
Both methods concern the same documented fibroid.
NCCI E.11 directs the completed-procedure pathway without adding the attempted ablation of that fibroid.
The operative narrative should retain the change and reason, while the claim follows the supported current entry.

Reference sections: E.11

Practice the linked chart questions