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.

Assessment

Synthetic record, September 9, 2026. An adult has persistent left shoulder swelling and pain. The clinician documents an effusion in the glenohumeral joint and two surrounding bursal fluid collections, labeled B1 and B2 on the ultrasound target map. Aspiration is planned for each documented collection.

Signed procedure note

Using ultrasound guidance for all three targets, the clinician aspirates fluid from the left shoulder joint and each of its two surrounding bursae. The report identifies the target for each aspiration; saved images and an interpretation document guidance. No other joint, tendon sheath or unrelated site is treated.

Specimen and follow-up record

The joint and bursal samples are labeled by target and sent for the ordered studies. No therapeutic drug injection or separate diagnostic ultrasound study is performed. The puncture sites are dressed and follow-up instructions are given. Needle changes and separate specimen containers are recorded.

Procedure worksheet

A draft reports three arthrocentesis procedure units because three collections were aspirated. Apply the Medicare NCCI joint-and-surrounding-bursae rule before selecting the full ultrasound-guided entry. This worksheet counts aspiration procedure units, not laboratory tests, supplies or specimen containers.

Your coding worksheet

Map the joint and two surrounding bursae to the left shoulder.
Identify the completed service and guidance method.
Correct the three-unit proposal under the cited anatomical-unit rule.
Explain why punctures, specimen containers and guidance images do not create more aspiration units.

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 glenohumeral joint and B1/B2 are one shoulder joint and its surrounding bursae; no second joint is treated.
The clinician performs aspiration with ultrasound guidance, documented with saved images and an interpretation. The final entry must match the completed service.
NCCI H.7 allows one procedure unit for that joint and its surrounding bursae, even though three targets were aspirated.
Needle changes, samples and guidance documentation do not multiply that unit. Use the complete guided arthrocentesis entry and its inclusion instructions; no separate diagnostic ultrasound study is documented.

Reference sections: H.7

Practice the linked chart questions