An arthroscopic repair becomes open

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 musculoskeletal professional service

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

Preoperative assessment

Synthetic record, September 9, 2026. An adult has a documented chronic full-thickness right supraspinatus tendon tear with persistent weakness despite conservative care. The surgeon plans arthroscopic rotator cuff repair. The decision to repair the tear is established before surgery.

Signed operative report

The surgeon begins therapeutic arthroscopy of the right shoulder and attempts to mobilize the torn tendon. Retraction prevents completion of the repair through the arthroscopic approach. The surgeon converts to an open approach, mobilizes the tendon and completes fixation of the tear to its insertion with anchors.

Completion note

The surgeon checks fixation and closes the wound. Initial arthroscopic inspection was part of the planned therapeutic approach. No independent diagnostic arthroscopy established a new decision for open surgery, and no opposite-shoulder procedure or separate arthroscopic repair is performed.

Procedure worksheet

One proposed claim lists attempted therapeutic arthroscopy plus completed open repair. Another replaces the attempted repair with a diagnostic arthroscopy line. Evaluate both under Medicare NCCI’s conversion rule, using the completed right rotator cuff repair for the authorized-entry lookup.

Your coding worksheet

Identify the planned and completed approaches.
Distinguish conversion from an independent diagnostic decision.
Evaluate both proposed extra arthroscopy lines.
Use the completed operation for the licensed-entry lookup.

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

Therapeutic arthroscopy of a known right rotator cuff tear was attempted, then converted to completed open repair of the same tear.
The record does not describe an independent diagnostic study whose findings established the decision for open surgery; the initial inspection belongs to the attempted therapeutic approach.
NCCI E.3 allows the completed open procedure, without an additional attempted surgical arthroscopy or a relabeled diagnostic arthroscopy line.
Use the right-shoulder site, chronic tear and completed open rotator cuff repair to verify the current authorized entry and instructions.

Reference sections: E.3

Practice the linked chart questions