HS292 Unit 4 Planned vs Performed Procedure Set Example

More Intention Than Accomplishment: A Unit 4 Procedure Coding Set Coding Only What Five Procedure Notes Say Was Completed

[Student Name]

Purdue University Global

HS292: Billing and Coding Practicum

Unit 4 Procedure Coding Set

[Instructor Name]

[Date]

The five procedure notes are composite; the procedure code set and federal coding policy cited are real, and codes and modifiers should be confirmed against the year and payer your section uses.

How Each Answer Is Built

Every case gives a short procedure note, then three rows: performed, not performed and the code with its descriptor paraphrased. Each answer starts by quoting the sentence that establishes what was completed, because that sentence is the evidence for everything after it. Cases are arranged by why the plan fell short: a finding that made it unnecessary, a first method that failed, an anatomical barrier and a patient decision.

Case 1: A Finding Made the Plan Unnecessary

Note: Right knee arthroscopy scheduled for partial medial meniscectomy for suspected tear. "Arthroscope introduced through standard portals; all three compartments inspected. Medial and lateral menisci intact without tear. Mild chondral softening, medial femoral condyle. No intervention required."

Performed: diagnostic arthroscopy of the knee. Not performed: meniscectomy. Code: diagnostic knee arthroscopy, a separate procedure [29870].

The schedule said meniscectomy, but the note says the menisci were intact. Coding the meniscectomy [29881] would report a procedure that did not happen. The postoperative diagnosis also changes, from a suspected tear to the chondral finding.

Case 2: A First Method Failed

Note: Emergency department, anterior dislocation of the left shoulder. "Reduction attempted with external rotation technique without sedation; unsuccessful. Procedural sedation administered by the emergency physician; reduction achieved with traction-countertraction. Post-reduction film confirms reduction."

Performed: one closed treatment of a shoulder dislocation with manipulation. Not performed as a separate service: the failed first attempt. Code: closed treatment of shoulder dislocation with manipulation [code chosen by the anesthesia requirement in the descriptor], with the sedation reported separately only if payer rules and documentation of time and monitoring support it.

Two attempts and one result produce one code, because the procedure code describes the treatment of the dislocation, not each try at it.

Case 3: A First Method Failed, Again

Note: "Left ear: cerumen impaction noted. Irrigation with warm water attempted; impaction persists. Cerumen removed with curette under direct visualization with otoscope. Tympanic membrane intact."

Performed: removal of impacted cerumen using instrumentation, left ear. Not performed as a separate service: the irrigation. Code: removal of impacted cerumen requiring instrumentation, unilateral [69210].

The irrigation code [69209] is not added. Federal edit policy does not allow both removal methods to be reported for the same ear on the same day, and the instrumentation service absorbs the irrigation that preceded it (Centers for Medicare & Medicaid Services, 2025a).

Case 4: An Anatomical Barrier

Note: Upper endoscopy planned with examination to the second part of the duodenum. "Scope passed to the stomach. Pyloric channel stenotic; scope could not be advanced into the duodenum. Stomach and esophagus examined fully. Repeat examination not planned."

Performed: esophagogastroscopy without examination of the duodenum. Not performed: duodenal examination. Code: diagnostic esophagogastroduodenoscopy [43235] with a modifier for reduced services.

The procedure code guidance directs that when the duodenum is not examined because the clinical situation prevents it, the base code is reported with the reduced services modifier if no repeat is planned, or the discontinued procedure modifier if a repeat is planned (American Medical Association, 2025). The phrase "repeat examination not planned" decides the modifier.

Case 5: A Patient Decision

Note: Dermatology office, shave removal planned of three seborrheic keratoses on the back. "First lesion, 0.8 cm, upper back, removed by shave. Patient then declined removal of remaining two lesions, preferring to wait. Hemostasis achieved."

Performed: one shave removal. Not performed: two shave removals. Code: shave removal of a single lesion of the trunk, lesion diameter 0.6 to 1.0 cm [code from the shave removal range by site and size].

The patient's decision does not call for a modifier here, because the completed service was performed in full; the two lesions not treated were simply never started. Modifiers for reduced or discontinued services apply to a procedure that was itself cut short, not to procedures that did not begin.

When the Note Is Not Clear

Each of these notes says plainly what was finished. Real notes are not always so obliging. If an endoscopy note never says how far the scope went, or a reduction note does not say which attempt succeeded, the coder cannot fill the gap from the schedule or the consent form. The right step is a query to the proceduralist asking what was completed, phrased without suggesting an answer. Two of the five cases here would have needed one if a single sentence had been left out, which is a reason to read the completed-step sentence first in every note.

The Diagnosis Side Changes Too

When a procedure falls short, the reason usually belongs on the claim. In Case 1 the postoperative finding replaces the suspected tear. In Case 4 the stenotic pyloric channel explains why the duodenum was not reached and supports the reduced service. In Case 5 the seborrheic keratosis is coded for the lesion removed.

What Holds Across the Five

In every case, the code follows the sentence describing what was completed. Plans, schedules and first attempts are context. Medicare's claims manual makes the same point for physician services: payment is for services furnished and documented, not for services intended (Centers for Medicare & Medicaid Services, 2025b).

References

American Medical Association. (2025). CPT 2026 professional edition. American Medical Association.

Centers for Medicare & Medicaid Services. (2025a). National Correct Coding Initiative policy manual for Medicare services. U.S. Department of Health and Human Services.

Centers for Medicare & Medicaid Services. (2025b). Medicare claims processing manual, chapter 12: Physicians/nonphysician practitioners. U.S. Department of Health and Human Services.