Evaluation before a planned operation

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

Chart gym · Original fictional record

Service date: 2026-08-20 · Physician office, outpatient

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

Purpose of this encounter

An adult attends an office encounter devoted solely to a preoperative medical evaluation. The operation is scheduled for a different date. This is an original fictional teaching chart.

Reason for the planned surgery

The surgeon has documented an age-related nuclear cataract of the right eye as the reason for a planned operation. Today is the medical evaluation requested before that operation; no cataract procedure is performed.

Evaluation

The clinician completes the requested evaluation and reviews documented essential hypertension because it affects the preoperative assessment. The record states no new acute complaint or additional diagnosis from this evaluation.

Assessment

Preoperative medical evaluation. Right age-related nuclear cataract is the reason for the planned operation. Essential hypertension is reviewed in the assessment. There is no postoperative diagnosis because the operation has not occurred.

Task boundary

This exercise asks for the diagnosis-sequencing framework. It deliberately does not supply a surgical code choice or ask the learner to report a service that will occur in the future.

Your coding worksheet

Identify which encounter is being coded today.
Explain the first-listed approach under the specific preoperative-evaluation guideline.
State where the documented cataract and hypertension belong, then verify each supported entry in the index and Tabular List.
Explain how an encounter for the operation itself would require a different guideline review.

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

Today's encounter is solely the preoperative medical evaluation. The future operation is a separate event.
Section IV.M directs the appropriate preprocedural examination code first, followed by the condition prompting surgery and findings related to the evaluation.
The cataract remains the reason for the planned surgery and the hypertension affects this evaluation. Apply the specific preoperative sequence; the future surgical diagnosis does not displace its first-listed instruction.
For ambulatory surgery itself, consult IV.N and the finalized surgical documentation. Do not import a hypothetical postoperative diagnosis into today's record.

Reference sections: IV.M–N

Practice the linked chart questions