Procedure-Specific Scenario Tutorials

The following seven scenarios are outlined as a guide on how to log certain bilateral procedures and/or procedures where multiple residents participated in the case, as it relates to how the procedures will be counted for accreditation. 

Please note: Each resident is responsible for recording his/her own experience in the RSL. For more information, see the FAQs.

Scenario 1:  Bilateral Sagittal Split Osteotomy of the Mandible With Rigid Fixation (Resident A and Resident B)

Resident (A) operates on the left side, while Resident (B) operates on the right side, performing equivalent procedures while the attending surgeon retracts for each of these residents.

In this scenario, each resident would log the case: 

• Resident (A) records this case with the role “Primary Surgeon” and CPT 21196, indicating left side in the procedure comments.
• Resident (B) records this case with the role “Primary Surgeon” and CPT 21196, indicating right side in the procedure comments.

For accreditation, this will be counted as two separate procedures.   It is imperative each resident enters the same MRN number and uses the same procedure code.  The residents should not also log the procedures in the first assistant role, because in this scenario, they serve as first assistant to another resident and not the attending surgeon.

Scenario 2:  Bilateral Sagittal Split Osteotomy Of The Mandible With Rigid Fixation (Attending Surgeon, Resident A, and Resident B)

The attending surgeon operates on the right side, with the chief resident (A) serving as first assistant. The chief resident (A) operates on the left side with the attending serving as first assistant.  A second resident (B) serves as a second assistant. 

In this scenario, the chief resident records this procedure twice:

• As role “first assistant” to the attending surgeon, CPT 21196, with right specified in the procedure comments
• As role “primary surgeon”, CPT 21196, with left mandible specified in the comments.

For accreditation purposes, both experiences recorded as “first assistant” and as “primary surgeon” are counted for a total of two procedures. Resident (B) CANNOT log a procedure for accreditation purposes as second assistant.

Scenario 3:  Composite Resection of the Tongue, Mandible and Ipsilateral Radical Neck Dissection With Bone Plate Placement and Soft Tissue Reconstruction With A Pectoralis Major Myocutaneous Flap For Stage IV Squamous Cell Carcinoma (Attending Surgeon and Chief Resident)

The case is managed entirely by the OMS service with one attending and one chief resident. The chief resident serves as a first assistant to the attending while the attending OMS performs the composite resection (CPT 41155). The chief resident serves as the primary surgeon for the bone plate placement (CPT 21244) and the primary surgeon for the pectoralis major myocutaneous flap (CPT 15734).  

In this scenario, the chief resident records this scenario twice:

1. As role “first assistant”, CPT 41155
2. As role “primary surgeon”, CPT codes 21244 and 15734

For accreditation purposes, all three procedures count.

Scenario 4:  Composite Resection Of The Tongue, Mandible And Ipsilateral Radical Neck Dissection With Bone Plate Placement And Soft Tissue Reconstruction With A Pectoralis Major Myocutaneous Flap For Stage IV Squamous Cell Carcinoma.  (Attending Surgeon, Chief Resident, Junior Resident)

The case is managed entirely by the OMS service with one attending, one chief resident (A), and one junior resident(B).  The chief resident (A) serves as a first assistant to the attending OMS while the attending OMS performs the composite resection (CPT 41155). The junior resident (B) serves as the primary surgeon for the bone plate placement (CPT 21244) with the chief resident serving as the second assistant for the bone plate placement.  The chief resident (A) performs the pectoralis major myocutaneous flap (CPT 15734) with the attending surgeon serving as the first assistant, and the junior resident serving as the second assistant.  

In this scenario, the chief resident records this case twice:

1. As role “first assistant”, CPT 41155
2. As role “Primary Surgeon”, CPT 15734

The chief resident would not record their experience as second assistant for accreditation purposes.

The junior resident records this case once:

1. As role “Primary Surgeon”, CPT 21244.

The junior resident would not record their experience as second assistant for accreditation purposes.

For accreditation purposes, the primary surgeon and first assistant roles are counted, for a total of three procedures. 

Scenario 5:  Open Reduction of Bilateral Mandibular Fractures (Attending Surgeon and Resident A)

The attending surgeon operates on the right side, with the chief resident (A) serving as first assistant. The chief resident (A) operates on the left side with the attending serving as first assistant.  A second resident (B) serves as a second assistant. 

In this scenario, the chief resident records this procedure twice:

• As role “first assistant” to the attending surgeon, CPT 21470, with right mandible specified in the procedure comments
• As role “primary surgeon”, CPT 21196, with left mandible specified in the comments.

For accreditation, this procedure will be counted as two separate procedures.  It is imperative each resident enters the same MRN number and uses the same procedure code. Resident (B) CANNOT log a procedure for accreditation purposes as second assistant.

Scenario 6:  Open Reduction of Bilateral Mandibular Fractures (Resident A and Resident B)

Resident (A) operates on the left side while Resident (B) operates on the right side, performing equivalent procedures while the attending surgeon retracts for each of these residents.

In this scenario, each resident records their experience:

• Resident (A) records this case with the role “Primary Surgeon” and CPT 21470, indicating left side in the procedure comments.
• Resident (B) records this case with the role “Primary Surgeon” and CPT 21470, indicating right side in the procedure comments.

For accreditation, this procedure will be counted as two separate procedures. It is imperative each resident enters the same MRN number and uses the same procedure code. The residents should not also log the procedures in the first assistant role, because in this scenario, they serve as first assistant to another resident and not the attending surgeon.

Scenario 7:  Open Reduction of A Left Mandibular Body Fracture And Closed Reduction Of A Right Subcondylar Fracture. 

The chief resident (A) performs the open reduction procedure after placement of arch bars or some form of MMF.  The MMF remains postoperatively to serve as the closed reduction of the subcondylar fracture.  In this scenario, the chief resident would record this procedure once:

1. As role “Primary Surgeon”, CPT 21470

For accreditation purposes, only the open reduction is counted. The closed reduction is inherent to the open reduction and CANNOT be logged in this scenario.