Managing Your Practice

Every profession and industry has paid close attention to customer satisfaction for decades—every one, that is, except medicine. Though physicians have always been deeply concerned with the quality of their care, they have seldom if ever sought input on their performance from patients themselves.

The traditional feeling among doctors—that as long as our skills are top-notch, how our patients feel about their care is irrelevant—is obsolete; patients' opinions do matter. Your patients can help you identify ways of improving your practice, which can lead to better care. Furthermore, soliciting your patients' opinions shows them something you already know: that you're interested in quality and want them to be happy.

Feedback can be solicited in a variety of ways: phone surveys, written surveys, focus groups, or personal interviews. Most practices will want to use written surveys, which tend to be the most cost effective and reliable approach.

To take a written survey, you can create a questionnaire from scratch or use a product that's already been developed by an outside vendor. Most experts recommend the latter, unless you have a very specialized practice and very specific questions to ask, because the time and effort involved in assembling your own questionnaire is simply prohibitive. Even with the best of intentions, you'll probably never get around to it. Besides, a vendor's questionnaire will have been tested and validated by prior use.

Commercial questionnaires abound. A new service called DrScore (www.DrScore.com

Whether you buy a questionnaire or write it yourself, keep the questions as simple as possible, and concentrate on what the experts call the top three issues: quality (are your patients satisfied with their care?), access (is it easy to obtain a referral and make an appointment?), and interpersonal issues (are physicians and staff caring and compassionate?).

Most questions should be answered using a scale, so that your responses can be quantified. Whether your scale ranges from 1 to 10, 1 to 5 (the most popular), 1 to 4 (which I favor because it forces a “sided” response), or something else, be sure to use the same one for all questions. If you use a 4-point scale on some questions and a 5-point scale on others, you won't be able to compare the results.

Then include two or three open-ended questions: “What do you like best about our practice?” or “What are we doing especially well?” and “What can we do to improve?” And then the key question: “Overall, how satisfied are you with your physician?”

Though verbatim comments aren't easy to tabulate, they will help you understand what is behind a score of 4.2 out of 5. And it's important to know, in your patients' own words, what they are saying to their friends and colleagues about you.

You should also collect some demographic information, so you can identify how certain groups of patients responded to particular questions. If younger patients like you better than older ones, for example, you should know that and try to discover why that is so. It's also useful to ask each patient to name his or her health plan; satisfaction scores may vary from plan to plan.

Patients are more likely to answer survey questions honestly if they believe their identity is protected, so make every effort to keep the entire survey process anonymous. But in cases where patients want to provide their names so they can ask to have a staff member contact them about their comments or concerns, by all means give them that option.

Don't expect everyone to respond; 30%–35% is a typical response rate. And while an adequate response rate is important, the number of responses you receive is a higher priority. If your response is 40% but you've surveyed only 100 patients, you won't have enough data to draw meaningful conclusions. The more responses you can get, the more valid and reliable your results are likely to be. Experts disagree on the minimum necessary, but most say your sampling should exceed 250 to achieve an acceptable margin of error.

The primary challenge emerges when completed surveys are returned. Few practices have the time or resources to properly analyze survey data. Consider outsourcing this step and send the complete surveys to a firm that specializes in health care data analysis.

Finally, what should you do with the results? While you don't have to act on every suggestion that your patients give you, you should take action on the key items that are causing dissatisfaction. Remember that your goal is to improve quality, not to place blame.

 

Although your improvement projects will focus on areas of weakness, make sure you also plan to celebrate your practice's successes. When you conduct a patient-satisfaction survey, chances are you're going to get a lot of positive reinforcement about the many things that you are doing well, and that's valuable information, too. It's important for you and your staff to know that there are many patients with a positive image and good feelings about your office.

DR. EASTERN practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, write Dr. Eastern at our editorial offices or e-mail him at [email protected]

Every profession and industry has paid close attention to customer satisfaction for decades—every one, that is, except medicine. Though physicians have always been deeply concerned with the quality of their care, they have seldom if ever sought input on their performance from patients themselves.

The traditional feeling among doctors—that as long as our skills are top-notch, how our patients feel about their care is irrelevant—is obsolete; patients' opinions do matter. Your patients can help you identify ways of improving your practice, which can lead to better care. Furthermore, soliciting your patients' opinions shows them something you already know: that you're interested in quality and want them to be happy.

Feedback can be solicited in a variety of ways: phone surveys, written surveys, focus groups, or personal interviews. Most practices will want to use written surveys, which tend to be the most cost effective and reliable approach.

To take a written survey, you can create a questionnaire from scratch or use a product that's already been developed by an outside vendor. Most experts recommend the latter, unless you have a very specialized practice and very specific questions to ask, because the time and effort involved in assembling your own questionnaire is simply prohibitive. Even with the best of intentions, you'll probably never get around to it. Besides, a vendor's questionnaire will have been tested and validated by prior use.

Commercial questionnaires abound. A new service called DrScore (www.DrScore.com

Whether you buy a questionnaire or write it yourself, keep the questions as simple as possible, and concentrate on what the experts call the top three issues: quality (are your patients satisfied with their care?), access (is it easy to obtain a referral and make an appointment?), and interpersonal issues (are physicians and staff caring and compassionate?).

Most questions should be answered using a scale, so that your responses can be quantified. Whether your scale ranges from 1 to 10, 1 to 5 (the most popular), 1 to 4 (which I favor because it forces a “sided” response), or something else, be sure to use the same one for all questions. If you use a 4-point scale on some questions and a 5-point scale on others, you won't be able to compare the results.

Then include two or three open-ended questions: “What do you like best about our practice?” or “What are we doing especially well?” and “What can we do to improve?” And then the key question: “Overall, how satisfied are you with your physician?”

Though verbatim comments aren't easy to tabulate, they will help you understand what is behind a score of 4.2 out of 5. And it's important to know, in your patients' own words, what they are saying to their friends and colleagues about you.

You should also collect some demographic information, so you can identify how certain groups of patients responded to particular questions. If younger patients like you better than older ones, for example, you should know that and try to discover why that is so. It's also useful to ask each patient to name his or her health plan; satisfaction scores may vary from plan to plan.

Patients are more likely to answer survey questions honestly if they believe their identity is protected, so make every effort to keep the entire survey process anonymous. But in cases where patients want to provide their names so they can ask to have a staff member contact them about their comments or concerns, by all means give them that option.

Don't expect everyone to respond; 30%–35% is a typical response rate. And while an adequate response rate is important, the number of responses you receive is a higher priority. If your response is 40% but you've surveyed only 100 patients, you won't have enough data to draw meaningful conclusions. The more responses you can get, the more valid and reliable your results are likely to be. Experts disagree on the minimum necessary, but most say your sampling should exceed 250 to achieve an acceptable margin of error.

The primary challenge emerges when completed surveys are returned. Few practices have the time or resources to properly analyze survey data. Consider outsourcing this step and send the complete surveys to a firm that specializes in health care data analysis.

Finally, what should you do with the results? While you don't have to act on every suggestion that your patients give you, you should take action on the key items that are causing dissatisfaction. Remember that your goal is to improve quality, not to place blame.

 

Although your improvement projects will focus on areas of weakness, make sure you also plan to celebrate your practice's successes. When you conduct a patient-satisfaction survey, chances are you're going to get a lot of positive reinforcement about the many things that you are doing well, and that's valuable information, too. It's important for you and your staff to know that there are many patients with a positive image and good feelings about your office.

DR. EASTERN practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, write Dr. Eastern at our editorial offices or e-mail him at [email protected]

Every profession and industry has paid close attention to customer satisfaction for decades—every one, that is, except medicine. Though physicians have always been deeply concerned with the quality of their care, they have seldom if ever sought input on their performance from patients themselves.

The traditional feeling among doctors—that as long as our skills are top-notch, how our patients feel about their care is irrelevant—is obsolete; patients' opinions do matter. Your patients can help you identify ways of improving your practice, which can lead to better care. Furthermore, soliciting your patients' opinions shows them something you already know: that you're interested in quality and want them to be happy.

Feedback can be solicited in a variety of ways: phone surveys, written surveys, focus groups, or personal interviews. Most practices will want to use written surveys, which tend to be the most cost effective and reliable approach.

To take a written survey, you can create a questionnaire from scratch or use a product that's already been developed by an outside vendor. Most experts recommend the latter, unless you have a very specialized practice and very specific questions to ask, because the time and effort involved in assembling your own questionnaire is simply prohibitive. Even with the best of intentions, you'll probably never get around to it. Besides, a vendor's questionnaire will have been tested and validated by prior use.

Commercial questionnaires abound. A new service called DrScore (www.DrScore.com

Whether you buy a questionnaire or write it yourself, keep the questions as simple as possible, and concentrate on what the experts call the top three issues: quality (are your patients satisfied with their care?), access (is it easy to obtain a referral and make an appointment?), and interpersonal issues (are physicians and staff caring and compassionate?).

Most questions should be answered using a scale, so that your responses can be quantified. Whether your scale ranges from 1 to 10, 1 to 5 (the most popular), 1 to 4 (which I favor because it forces a “sided” response), or something else, be sure to use the same one for all questions. If you use a 4-point scale on some questions and a 5-point scale on others, you won't be able to compare the results.

Then include two or three open-ended questions: “What do you like best about our practice?” or “What are we doing especially well?” and “What can we do to improve?” And then the key question: “Overall, how satisfied are you with your physician?”

Though verbatim comments aren't easy to tabulate, they will help you understand what is behind a score of 4.2 out of 5. And it's important to know, in your patients' own words, what they are saying to their friends and colleagues about you.

You should also collect some demographic information, so you can identify how certain groups of patients responded to particular questions. If younger patients like you better than older ones, for example, you should know that and try to discover why that is so. It's also useful to ask each patient to name his or her health plan; satisfaction scores may vary from plan to plan.

Patients are more likely to answer survey questions honestly if they believe their identity is protected, so make every effort to keep the entire survey process anonymous. But in cases where patients want to provide their names so they can ask to have a staff member contact them about their comments or concerns, by all means give them that option.

Don't expect everyone to respond; 30%–35% is a typical response rate. And while an adequate response rate is important, the number of responses you receive is a higher priority. If your response is 40% but you've surveyed only 100 patients, you won't have enough data to draw meaningful conclusions. The more responses you can get, the more valid and reliable your results are likely to be. Experts disagree on the minimum necessary, but most say your sampling should exceed 250 to achieve an acceptable margin of error.

The primary challenge emerges when completed surveys are returned. Few practices have the time or resources to properly analyze survey data. Consider outsourcing this step and send the complete surveys to a firm that specializes in health care data analysis.

Finally, what should you do with the results? While you don't have to act on every suggestion that your patients give you, you should take action on the key items that are causing dissatisfaction. Remember that your goal is to improve quality, not to place blame.

 

Although your improvement projects will focus on areas of weakness, make sure you also plan to celebrate your practice's successes. When you conduct a patient-satisfaction survey, chances are you're going to get a lot of positive reinforcement about the many things that you are doing well, and that's valuable information, too. It's important for you and your staff to know that there are many patients with a positive image and good feelings about your office.

DR. EASTERN practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, write Dr. Eastern at our editorial offices or e-mail him at [email protected]

Undisclosed Massachusetts venue

A woman of Mediterranean descent with chronic anemia presented to a nurse practitioner for a birth control injection. In the woman’s chart—which the supervising physician also signed—the nurse practitioner expressed concern that the patient might suffer from thalassemia, but the clinicians did not evaluate her condition or advise her of the pregnancy risks associated with the disorder.

Two years later the woman became pregnant. At her first prenatal visit, both her family history and blood work were noted to be worrisome relative to thalassemia. Again, however, no steps were taken to evaluate either mother or fetus.

The woman gave birth to an infant daughter who was subsequently diagnosed with thalassemia major, which requires her to undergo blood transfusions every 4 weeks and will likely shorten her life expectancy.

In suing, the plaintiff argued that clinicians should have tested the mother and father for the thalassemia trait, which both were found to have after the child’s diagnosis. Further, she claimed, tests should have been performed to determine whether the fetus had the disorder.

The defense argued that the incidence of thalassemia transmission from mother to fetus is very low and maintained the woman was aware of her status as a thalassemia carrier and knew the risks involved with pregnancy.

• The parties settled for $900,000.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Undisclosed Massachusetts venue

A woman of Mediterranean descent with chronic anemia presented to a nurse practitioner for a birth control injection. In the woman’s chart—which the supervising physician also signed—the nurse practitioner expressed concern that the patient might suffer from thalassemia, but the clinicians did not evaluate her condition or advise her of the pregnancy risks associated with the disorder.

Two years later the woman became pregnant. At her first prenatal visit, both her family history and blood work were noted to be worrisome relative to thalassemia. Again, however, no steps were taken to evaluate either mother or fetus.

The woman gave birth to an infant daughter who was subsequently diagnosed with thalassemia major, which requires her to undergo blood transfusions every 4 weeks and will likely shorten her life expectancy.

In suing, the plaintiff argued that clinicians should have tested the mother and father for the thalassemia trait, which both were found to have after the child’s diagnosis. Further, she claimed, tests should have been performed to determine whether the fetus had the disorder.

The defense argued that the incidence of thalassemia transmission from mother to fetus is very low and maintained the woman was aware of her status as a thalassemia carrier and knew the risks involved with pregnancy.

• The parties settled for $900,000.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Undisclosed Massachusetts venue

A woman of Mediterranean descent with chronic anemia presented to a nurse practitioner for a birth control injection. In the woman’s chart—which the supervising physician also signed—the nurse practitioner expressed concern that the patient might suffer from thalassemia, but the clinicians did not evaluate her condition or advise her of the pregnancy risks associated with the disorder.

Two years later the woman became pregnant. At her first prenatal visit, both her family history and blood work were noted to be worrisome relative to thalassemia. Again, however, no steps were taken to evaluate either mother or fetus.

The woman gave birth to an infant daughter who was subsequently diagnosed with thalassemia major, which requires her to undergo blood transfusions every 4 weeks and will likely shorten her life expectancy.

In suing, the plaintiff argued that clinicians should have tested the mother and father for the thalassemia trait, which both were found to have after the child’s diagnosis. Further, she claimed, tests should have been performed to determine whether the fetus had the disorder.

The defense argued that the incidence of thalassemia transmission from mother to fetus is very low and maintained the woman was aware of her status as a thalassemia carrier and knew the risks involved with pregnancy.

• The parties settled for $900,000.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A woman was admitted in the evening for induction of labor for a planned vaginal birth after cesarean (VBAC) delivery. Normal labor did not ensue after oxytocin was administered in the morning, and the fetal heart rate monitor strips revealed uterine hyperactivity and fetal distress, which worsened during the day.

The nurse assigned to the woman asked the charge nurse for advice; she was told to call the obstetrician. The physician claimed the labor was progressing satisfactorily and ordered continuation of the oxytocin. After alerting the charge nurse at 3:30 PM, the evening shift nurse and the charge nurse stopped the oxytocin at 4:00 PMand called the obstetrician at 4:10 PM. The physician returned to the hospital but did not order a cesarean until 20 minutes later.

The infant had a seizure shortly after birth, and the physician diagnosed hypoxic brain injury as a result of uterine rupture. The baby died 3 weeks later.

In suing, the woman claimed she was not advised of the risks of VBAC delivery, that the charge nurse failed to recognize early signs of fetal distress, that a cesarean should have been ordered much earlier in the day, and that it was negligent to allow labor to continue into the afternoon.

The obstetrician claimed the infant was healthy during early labor and faulted the evening nurse for not calling him back to the hospital sooner. The nurses claimed the physician had superior knowledge and said they could not be expected to recognize distress on the fetal monitor if the obstetrician could not.

• The parties reached a $1.25 million settlement.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A woman was admitted in the evening for induction of labor for a planned vaginal birth after cesarean (VBAC) delivery. Normal labor did not ensue after oxytocin was administered in the morning, and the fetal heart rate monitor strips revealed uterine hyperactivity and fetal distress, which worsened during the day.

The nurse assigned to the woman asked the charge nurse for advice; she was told to call the obstetrician. The physician claimed the labor was progressing satisfactorily and ordered continuation of the oxytocin. After alerting the charge nurse at 3:30 PM, the evening shift nurse and the charge nurse stopped the oxytocin at 4:00 PMand called the obstetrician at 4:10 PM. The physician returned to the hospital but did not order a cesarean until 20 minutes later.

The infant had a seizure shortly after birth, and the physician diagnosed hypoxic brain injury as a result of uterine rupture. The baby died 3 weeks later.

In suing, the woman claimed she was not advised of the risks of VBAC delivery, that the charge nurse failed to recognize early signs of fetal distress, that a cesarean should have been ordered much earlier in the day, and that it was negligent to allow labor to continue into the afternoon.

The obstetrician claimed the infant was healthy during early labor and faulted the evening nurse for not calling him back to the hospital sooner. The nurses claimed the physician had superior knowledge and said they could not be expected to recognize distress on the fetal monitor if the obstetrician could not.

• The parties reached a $1.25 million settlement.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A woman was admitted in the evening for induction of labor for a planned vaginal birth after cesarean (VBAC) delivery. Normal labor did not ensue after oxytocin was administered in the morning, and the fetal heart rate monitor strips revealed uterine hyperactivity and fetal distress, which worsened during the day.

The nurse assigned to the woman asked the charge nurse for advice; she was told to call the obstetrician. The physician claimed the labor was progressing satisfactorily and ordered continuation of the oxytocin. After alerting the charge nurse at 3:30 PM, the evening shift nurse and the charge nurse stopped the oxytocin at 4:00 PMand called the obstetrician at 4:10 PM. The physician returned to the hospital but did not order a cesarean until 20 minutes later.

The infant had a seizure shortly after birth, and the physician diagnosed hypoxic brain injury as a result of uterine rupture. The baby died 3 weeks later.

In suing, the woman claimed she was not advised of the risks of VBAC delivery, that the charge nurse failed to recognize early signs of fetal distress, that a cesarean should have been ordered much earlier in the day, and that it was negligent to allow labor to continue into the afternoon.

The obstetrician claimed the infant was healthy during early labor and faulted the evening nurse for not calling him back to the hospital sooner. The nurses claimed the physician had superior knowledge and said they could not be expected to recognize distress on the fetal monitor if the obstetrician could not.

• The parties reached a $1.25 million settlement.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Suffolk County (NY) Supreme Court

A third-trimester sonogram showed the fetus in an oblique transverse lie, indicating possible breech presentation, along with hyperextension of the fetus’ spinal cord, indicating the fetus was at high risk for neck injury from a vaginal delivery. The radiologist conveyed the sonogram findings to a nurse, but not the woman’s obstetrician.

The next day the woman began having contractions and went to the emergency room. No attempt was made to obtain the sonogram from the day before. Despite a double-footling breech presentation, the obstetrician elected not to perform a cesarean section. After vaginal delivery, the infant was quadriplegic and had severe hypoxic brain damage.

In suing, the woman claimed her physician was negligent in choice of delivery and that the flexing and rotating of the infant’s head caused a near-complete transection of the spinal cord.

• The case settled for $11.8 million.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Suffolk County (NY) Supreme Court

A third-trimester sonogram showed the fetus in an oblique transverse lie, indicating possible breech presentation, along with hyperextension of the fetus’ spinal cord, indicating the fetus was at high risk for neck injury from a vaginal delivery. The radiologist conveyed the sonogram findings to a nurse, but not the woman’s obstetrician.

The next day the woman began having contractions and went to the emergency room. No attempt was made to obtain the sonogram from the day before. Despite a double-footling breech presentation, the obstetrician elected not to perform a cesarean section. After vaginal delivery, the infant was quadriplegic and had severe hypoxic brain damage.

In suing, the woman claimed her physician was negligent in choice of delivery and that the flexing and rotating of the infant’s head caused a near-complete transection of the spinal cord.

• The case settled for $11.8 million.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Suffolk County (NY) Supreme Court

A third-trimester sonogram showed the fetus in an oblique transverse lie, indicating possible breech presentation, along with hyperextension of the fetus’ spinal cord, indicating the fetus was at high risk for neck injury from a vaginal delivery. The radiologist conveyed the sonogram findings to a nurse, but not the woman’s obstetrician.

The next day the woman began having contractions and went to the emergency room. No attempt was made to obtain the sonogram from the day before. Despite a double-footling breech presentation, the obstetrician elected not to perform a cesarean section. After vaginal delivery, the infant was quadriplegic and had severe hypoxic brain damage.

In suing, the woman claimed her physician was negligent in choice of delivery and that the flexing and rotating of the infant’s head caused a near-complete transection of the spinal cord.

• The case settled for $11.8 million.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Undisclosed venue (Mich)

A woman complaining of tenderness in the right upper quadrant went to her gynecologist, who attributed the pain to a left ovary cyst. Despite the lack of further testing, the physician said the cyst was cancerous and recommended immediate removal. The woman consented to a laparoscopic oophorectomy.

The inferior epigastric artery was severed by the third-year resident who performed most of the procedure. After surgery, the woman had abdominal pain leading to distension, guarding, and tympany. She was unable to have a bowel movement or void, and a fever developed, leading to peritonitis/sepsis.

After her physician diagnosed ileus, a surgical consult on the 5th postoperative day revealed an immediately obvious 2-cm hole in the sigmoid colon. Because of the delay, the hole could not be repaired safely, and a colostomy was performed. Many abdominal surgeries were needed to remove necrotic bowel, drain abscesses, and reconstruct the abdominal wall.

In suing, the plaintiff alleged negligence in the failure to immediately detect the perforation during the initial procedure. She also claimed the oophorectomy was unnecessary and argued that the ovarian cyst would have resolved spontaneously over time.

The defendant argued that the woman had a “delayed rupture” of the colon.

• The case settled for $1 million at mediation.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Undisclosed venue (Mich)

A woman complaining of tenderness in the right upper quadrant went to her gynecologist, who attributed the pain to a left ovary cyst. Despite the lack of further testing, the physician said the cyst was cancerous and recommended immediate removal. The woman consented to a laparoscopic oophorectomy.

The inferior epigastric artery was severed by the third-year resident who performed most of the procedure. After surgery, the woman had abdominal pain leading to distension, guarding, and tympany. She was unable to have a bowel movement or void, and a fever developed, leading to peritonitis/sepsis.

After her physician diagnosed ileus, a surgical consult on the 5th postoperative day revealed an immediately obvious 2-cm hole in the sigmoid colon. Because of the delay, the hole could not be repaired safely, and a colostomy was performed. Many abdominal surgeries were needed to remove necrotic bowel, drain abscesses, and reconstruct the abdominal wall.

In suing, the plaintiff alleged negligence in the failure to immediately detect the perforation during the initial procedure. She also claimed the oophorectomy was unnecessary and argued that the ovarian cyst would have resolved spontaneously over time.

The defendant argued that the woman had a “delayed rupture” of the colon.

• The case settled for $1 million at mediation.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Undisclosed venue (Mich)

A woman complaining of tenderness in the right upper quadrant went to her gynecologist, who attributed the pain to a left ovary cyst. Despite the lack of further testing, the physician said the cyst was cancerous and recommended immediate removal. The woman consented to a laparoscopic oophorectomy.

The inferior epigastric artery was severed by the third-year resident who performed most of the procedure. After surgery, the woman had abdominal pain leading to distension, guarding, and tympany. She was unable to have a bowel movement or void, and a fever developed, leading to peritonitis/sepsis.

After her physician diagnosed ileus, a surgical consult on the 5th postoperative day revealed an immediately obvious 2-cm hole in the sigmoid colon. Because of the delay, the hole could not be repaired safely, and a colostomy was performed. Many abdominal surgeries were needed to remove necrotic bowel, drain abscesses, and reconstruct the abdominal wall.

In suing, the plaintiff alleged negligence in the failure to immediately detect the perforation during the initial procedure. She also claimed the oophorectomy was unnecessary and argued that the ovarian cyst would have resolved spontaneously over time.

The defendant argued that the woman had a “delayed rupture” of the colon.

• The case settled for $1 million at mediation.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

New York County (NY) Supreme Court

A 37-year-old white woman was implanted with what she thought were her own fertilized embryos. Her husband, who contributed the sperm, was also white. She gave birth to 2 healthy baby boys: 1 white and 1 black.

Further investigation revealed that the plaintiff had inadvertently received an embryo from a black woman who was present at the clinic at the same time for fertilization with her own embryos.

The black infant was returned to his parents 5 months after delivery, but a custody suit ensued. The embryologist admitted he had inserted some embryos from the black woman into the catheter that was used to implant the white woman.

• A confidential settlement was reached.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

New York County (NY) Supreme Court

A 37-year-old white woman was implanted with what she thought were her own fertilized embryos. Her husband, who contributed the sperm, was also white. She gave birth to 2 healthy baby boys: 1 white and 1 black.

Further investigation revealed that the plaintiff had inadvertently received an embryo from a black woman who was present at the clinic at the same time for fertilization with her own embryos.

The black infant was returned to his parents 5 months after delivery, but a custody suit ensued. The embryologist admitted he had inserted some embryos from the black woman into the catheter that was used to implant the white woman.

• A confidential settlement was reached.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

New York County (NY) Supreme Court

A 37-year-old white woman was implanted with what she thought were her own fertilized embryos. Her husband, who contributed the sperm, was also white. She gave birth to 2 healthy baby boys: 1 white and 1 black.

Further investigation revealed that the plaintiff had inadvertently received an embryo from a black woman who was present at the clinic at the same time for fertilization with her own embryos.

The black infant was returned to his parents 5 months after delivery, but a custody suit ensued. The embryologist admitted he had inserted some embryos from the black woman into the catheter that was used to implant the white woman.

• A confidential settlement was reached.
  

The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, of Nashville, Tenn (www.verdictslaska.com). While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.