Scenario #1

The patient was admitted to have a Thoracoscopic lobectomy performed. The patient has a
malignant neoplasm on the right middle lobe. Because of extensive pleural effusion, the
physician was unable to complete the endoscopic procedure that was started resulting in only
inspecting the pleural cavity. Root operation inspection PCs code 0WJ94 Z Z
Scenario #2:
Procedure: umbilical hernia repair
Details: the patient was placed supine on the operating table and induced with general anesthesia.
The abdomen was sterile prepared and draped, and the previous surgical incision was opened.
Sharp dissection led to identification of the hernia, which was dissected free of surrounding
tissue. The contents were reduced into the abdominal cavity. The facial edges were clean and
reapproximated with interrupted Ethelbound sutures. Subcutaneous was closed and then the skin
was closed. The patient was sent to recovery room in stable condition.
Root operation: repair
PCs code: 0 W QF0Z Z
Scenario #3
Description: Amy and bald is a 32 year old female who presents for a bilateral augmentation
mammoplasty. The patient is taken to the OR where general anesthesia was administered and the
chest prepped and draped. The procedure started on the left hand side with a 4 centimeter
incision being made under the breast. That section was carried down to subcutaneous layer. The
pictorials major muscle was then elevated off chest wall and medical pectorals attachments were
dissected creating a pocket. Attention was then turned to the right hand side, with the same
procedure being performed. Attention was then turned back to the left side and a 250CC McGann
style 468 implant was selected. This was emptied of all air and checked for leaks. The implant
was then enrolled and placed through the inframammary incision and unfurled. The implant was
then inflated to 310CC and appropriately positioned. The same procedure was then carried out on
the right side. The patient was then placed in a semi sitting position and implant positioning was
assessed and found to be appropriate. We’re enclosure was carried out and the patient was sent to
recovery and satisfactory condition.
Route operation: alteration
PCs code: 0H0V0JZ
Scenario #4
Jacqueline Jackson was brought back to the OR today, post op day 2, after having open heart
surgery for a post op hemorrhage. An incision is made at the previous incision site and the source
of bleeding was identified and corrected without any complications.
Route operation: control
PCs code : 0W380Z Z
Scenario #5
Procedure: spinal fusion
Description: Sam suffers is a 56 year old male who is seen today with a herniated disc in his
lumbar back. He has tried conservative treatment without success and presents today for a spinal
fusion. The patient is taken to the OR, prepped, draped, ANESTHELIZED and an open
posterior spinal fusion of the posterior column at L4-L5 using allograft bone grafting material
was performed. The patient tolerated procedure well and was transferred to recovery and stable
condition.
Root operation: fusion
PCs code: 0SG00K1
Scenario #6
Indication: gender reassignment surgery
Description of procedure: Tracy Timley is a 46 year old patient taken to the OR for a gender
reassignment surgery. The patient was given general anesthesia and was prepped and draped
appropriately. A male to female gender reassignment surgery in which a vagina is formed using
donor tissue was performed without any complications the patient was extubated and transferred
to the recovery room and stable condition.
Root operation: creation
PCS code: 0W4M0K0