Worksheet 4
1. Left reverse shoulder replacement, metal on polyethylene.
The PCS code for this procedure is:
0RRK00Z
2. Retropubic total prostatectomy.
The PCS code for this procedure is:
0VT00ZZ
3. Preoperative Diagnosis: Interstitial cystitis, Urethral stenosis
Postoperative Diagnosis: Interstitial cystitis, Urethral stenosis
Procedure: Cystoscopy. Urethral dilation and hydrodilation.
Procedure Notes: Urethra was tight at 26-French and dilated with 32-
French. Bladder neck is normal. Ureteral orifice is normal size, shape and
position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder
capacity is 700 mL under anesthesia. There is moderate glomerulation
consistent with interstitial cystitis at the end of hydrodilation. Residual urine
was 150 mL. The patient was brought to the cystoscopy suite and placed on
the table in lithotomy position. The patient was prepped and draped in the
usual sterile fashion. A 21 Olympus cystoscope was inserted and the bladder,
viewed with 12- and 70-degree lenses. Bladder was filled by gravity to
capacity, emptied and again cystoscopy was performed with findings as
above. Urethra was then calibrated with 32-French. The patient was taken to
the recovery room in stable condition.
ICD-10-PCS code:
0T7D8ZZ
4. Open reduction of a displaced right humeral shaft fracture.
The PCS code for this procedure is:
0PSF0ZZ
5. Colpopexy for vaginal prolapse, open approach.
The PCS code for this procedure is:
0USG0ZZ
, 6. Laparoscopic assisted vaginal hysterectomy.
The PCS code for this procedure is:
0UT9FZZ
7. Routine Foley catheter placement.
The PCS code for this procedure is:
0T9B70Z
8. Transplantation of left kidney, received from identical twin sister.
The PCS code for this procedure is:
0TY10Z1
9. Preoperative Diagnosis: Vulvar dysplasia
Postoperative Diagnosis: Vulvar dysplasia
Procedure: Partial vulvectomy and vulvar biopsies
Anesthesia: General endotracheal anesthesia
Procedure Notes: The patient was prepped and draped sterilely in the
lithotomy position. The lesions were at the base of the labia majora
bilaterally, extending onto the perineal body. An elliptical incision was made
starting about halfway up on the labia minora on the left, bringing it around
on the perineal body on the outside and around the hymenal ring on the
inside, up to about halfway up the labia on the opposite side. The Bovie
cautery was then used to undermine the subcutaneous tissues and the
specimen was marked at 12 o’clock and frozen section biopsy submitted to
pathology, proven to be dysplasia. I obtained frozen section biopsies from 2,
4 and 6 o’clock, and all were reported as negative for dysplasia. The area
was closed with a running, locking 2-0 Vicryl, starting in the midline and
working up the right labia and then starting in the midline and working up
the left labia. Gentamicin ointment was applied to the incision sites, and the
patient was then awakened and sent to recovery in stable condition.
ICD-10-PCS code:
0UBM0ZX
10. Hysteroscopy.
The PCS code for this procedure is:
1. Left reverse shoulder replacement, metal on polyethylene.
The PCS code for this procedure is:
0RRK00Z
2. Retropubic total prostatectomy.
The PCS code for this procedure is:
0VT00ZZ
3. Preoperative Diagnosis: Interstitial cystitis, Urethral stenosis
Postoperative Diagnosis: Interstitial cystitis, Urethral stenosis
Procedure: Cystoscopy. Urethral dilation and hydrodilation.
Procedure Notes: Urethra was tight at 26-French and dilated with 32-
French. Bladder neck is normal. Ureteral orifice is normal size, shape and
position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder
capacity is 700 mL under anesthesia. There is moderate glomerulation
consistent with interstitial cystitis at the end of hydrodilation. Residual urine
was 150 mL. The patient was brought to the cystoscopy suite and placed on
the table in lithotomy position. The patient was prepped and draped in the
usual sterile fashion. A 21 Olympus cystoscope was inserted and the bladder,
viewed with 12- and 70-degree lenses. Bladder was filled by gravity to
capacity, emptied and again cystoscopy was performed with findings as
above. Urethra was then calibrated with 32-French. The patient was taken to
the recovery room in stable condition.
ICD-10-PCS code:
0T7D8ZZ
4. Open reduction of a displaced right humeral shaft fracture.
The PCS code for this procedure is:
0PSF0ZZ
5. Colpopexy for vaginal prolapse, open approach.
The PCS code for this procedure is:
0USG0ZZ
, 6. Laparoscopic assisted vaginal hysterectomy.
The PCS code for this procedure is:
0UT9FZZ
7. Routine Foley catheter placement.
The PCS code for this procedure is:
0T9B70Z
8. Transplantation of left kidney, received from identical twin sister.
The PCS code for this procedure is:
0TY10Z1
9. Preoperative Diagnosis: Vulvar dysplasia
Postoperative Diagnosis: Vulvar dysplasia
Procedure: Partial vulvectomy and vulvar biopsies
Anesthesia: General endotracheal anesthesia
Procedure Notes: The patient was prepped and draped sterilely in the
lithotomy position. The lesions were at the base of the labia majora
bilaterally, extending onto the perineal body. An elliptical incision was made
starting about halfway up on the labia minora on the left, bringing it around
on the perineal body on the outside and around the hymenal ring on the
inside, up to about halfway up the labia on the opposite side. The Bovie
cautery was then used to undermine the subcutaneous tissues and the
specimen was marked at 12 o’clock and frozen section biopsy submitted to
pathology, proven to be dysplasia. I obtained frozen section biopsies from 2,
4 and 6 o’clock, and all were reported as negative for dysplasia. The area
was closed with a running, locking 2-0 Vicryl, starting in the midline and
working up the right labia and then starting in the midline and working up
the left labia. Gentamicin ointment was applied to the incision sites, and the
patient was then awakened and sent to recovery in stable condition.
ICD-10-PCS code:
0UBM0ZX
10. Hysteroscopy.
The PCS code for this procedure is:
