One joint and its surrounding bursae

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.

Encounter

A fictional adult has a documented indication for treatment of the left shoulder joint and two surrounding bursae. The clinician records the target locations and services actually furnished. This exercise stipulates that the work falls within the arthrocentesis family addressed by the cited NCCI unit rule.

Procedure record

The clinician performs the documented aspiration or injection work at the joint and its surrounding bursae during one encounter. The report identifies each target. More than one puncture and syringe is used, but there is no procedure on another joint.

Unit proposal

A draft charge reports three units because the clinician treated three targets. A second draft uses the number of needle changes. Neither draft applies the cited joint-and-surrounding-bursae unit relationship.

Remaining lookup

The current authorized entry still requires the specific service and any imaging-guidance distinction. The case does not establish a separate injection at an unrelated site or a separate diagnostic study. Review actual documented work before adding those services.

Your coding worksheet

Map the joint and surrounding bursae.
Identify the unit specified by the cited rule.
Explain why target, needle and syringe counts are insufficient.
Complete the exact service and guidance 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

All supplied targets belong to one joint and its surrounding bursae.
The cited NCCI family treats that relationship as the relevant single unit.
Puncture or supply counts do not replace the defined anatomical unit.
Use the full current entry to verify the actual service and guidance requirements; no unrelated service should be inferred.

Reference sections: H.7

Practice the linked chart questions