Fetus expelled to floor after D&C

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Los Angeles County (Calif) Superior Court

A 28-year-old woman in her first trimester learned that her fetus had no cardiac activity. A dilation and curettage (D&C) was performed.

At home following the procedure, the woman experienced abdominal pain. While in the bathroom, she expelled the fetus onto the floor. The patient required a second D&C procedure. When the woman and her husband requested the fetus for burial, they learned that it was sent to pathology, where it was destroyed.

In suing, the plaintiffs noted that medical records showed that, at the first D&C, only 50 cc of blood and minimal products of conception were collected. They alleged this should have prompted an ultrasound examination to ensure the fetus was completely removed.

The defendants denied negligence, noting that incomplete removal of the fetus is a known risk of the procedure.

  • The parties settled for $225,000 at arbitration.
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.
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Los Angeles County (Calif) Superior Court

A 28-year-old woman in her first trimester learned that her fetus had no cardiac activity. A dilation and curettage (D&C) was performed.

At home following the procedure, the woman experienced abdominal pain. While in the bathroom, she expelled the fetus onto the floor. The patient required a second D&C procedure. When the woman and her husband requested the fetus for burial, they learned that it was sent to pathology, where it was destroyed.

In suing, the plaintiffs noted that medical records showed that, at the first D&C, only 50 cc of blood and minimal products of conception were collected. They alleged this should have prompted an ultrasound examination to ensure the fetus was completely removed.

The defendants denied negligence, noting that incomplete removal of the fetus is a known risk of the procedure.

  • The parties settled for $225,000 at arbitration.
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.

Los Angeles County (Calif) Superior Court

A 28-year-old woman in her first trimester learned that her fetus had no cardiac activity. A dilation and curettage (D&C) was performed.

At home following the procedure, the woman experienced abdominal pain. While in the bathroom, she expelled the fetus onto the floor. The patient required a second D&C procedure. When the woman and her husband requested the fetus for burial, they learned that it was sent to pathology, where it was destroyed.

In suing, the plaintiffs noted that medical records showed that, at the first D&C, only 50 cc of blood and minimal products of conception were collected. They alleged this should have prompted an ultrasound examination to ensure the fetus was completely removed.

The defendants denied negligence, noting that incomplete removal of the fetus is a known risk of the procedure.

  • The parties settled for $225,000 at arbitration.
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.
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Nurses urge Ob/Gyn to perform cesarean

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Hillsborough County (Fla) Circuit Court

After passing 41 weeks’ gestation, a 30-year-old woman was admitted to the hospital and given oxytocin to induce labor. The fetal heart rate tracing was not reassuring and there was a deceleration to 45 beats per minute, which prompted nursing staff to urge the Ob/Gyn to conduct a cesarean section.

When the physician chose not to proceed with a cesarean, the nurses contacted a supervisor, who also recommended cesarean delivery. The doctor ordered an immediate cesarean, but changed the order from “stat” to “ASAP” when the child’s heart rate improved.

At delivery a nuchal cord was discovered. The infant, born with brain damage, was never able to walk, talk, or blink. He died of pneumonia at age 2.

The family claimed the doctor was negligent in not initiating cesarean sooner.

The defendant argued that the child suffered chronic hypoxia throughout pregnancy, and noted that placental pathology revealed significant abnormalities, including profound chorangiosis.

  • The jury awarded the plaintiffs $2.4 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.
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Hillsborough County (Fla) Circuit Court

After passing 41 weeks’ gestation, a 30-year-old woman was admitted to the hospital and given oxytocin to induce labor. The fetal heart rate tracing was not reassuring and there was a deceleration to 45 beats per minute, which prompted nursing staff to urge the Ob/Gyn to conduct a cesarean section.

When the physician chose not to proceed with a cesarean, the nurses contacted a supervisor, who also recommended cesarean delivery. The doctor ordered an immediate cesarean, but changed the order from “stat” to “ASAP” when the child’s heart rate improved.

At delivery a nuchal cord was discovered. The infant, born with brain damage, was never able to walk, talk, or blink. He died of pneumonia at age 2.

The family claimed the doctor was negligent in not initiating cesarean sooner.

The defendant argued that the child suffered chronic hypoxia throughout pregnancy, and noted that placental pathology revealed significant abnormalities, including profound chorangiosis.

  • The jury awarded the plaintiffs $2.4 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.

Hillsborough County (Fla) Circuit Court

After passing 41 weeks’ gestation, a 30-year-old woman was admitted to the hospital and given oxytocin to induce labor. The fetal heart rate tracing was not reassuring and there was a deceleration to 45 beats per minute, which prompted nursing staff to urge the Ob/Gyn to conduct a cesarean section.

When the physician chose not to proceed with a cesarean, the nurses contacted a supervisor, who also recommended cesarean delivery. The doctor ordered an immediate cesarean, but changed the order from “stat” to “ASAP” when the child’s heart rate improved.

At delivery a nuchal cord was discovered. The infant, born with brain damage, was never able to walk, talk, or blink. He died of pneumonia at age 2.

The family claimed the doctor was negligent in not initiating cesarean sooner.

The defendant argued that the child suffered chronic hypoxia throughout pregnancy, and noted that placental pathology revealed significant abnormalities, including profound chorangiosis.

  • The jury awarded the plaintiffs $2.4 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.
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New mother dies after normal delivery

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Cook County (Ill) Circuit Court

A few hours after an uncomplicated vaginal delivery, a 36-year-old woman began experiencing abdominal discomfort and back pain, which was diagnosed as a distended bladder and musculoskeletal pain. She received analgesics, but subsequently experienced pain in her abdomen and right shoulder so severe that she could not move.

Approximately an hour later, the woman suffered 2 seizures. Nursing staff identified these as eclamptic seizures and called the attending physician at home. Soon after, the woman’s blood pressure began to fall and she was brought to intensive care, where she was intubated and received blood due to low hemoglobin.

Though a surgical team was assembled, the woman could not be stabilized for surgery. She died soon after. Autopsy revealed the cause of death to be intraabdominal hemorrhage due a ruptured pancreatic cyst.

The woman’s family sued the hospital, alleging that if nursing staff had contacted the physician sooner, blood administration would have begun earlier, allowing the woman to get to the operating room for surgery.

The defense argued that the woman hemorrhaged too quickly for an effective intervention to occur. Further, it maintained that the nurses’ assessment of eclamptic seizures was reasonable.

  • The jury awarded the plaintiff $12.4 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.
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Cook County (Ill) Circuit Court

A few hours after an uncomplicated vaginal delivery, a 36-year-old woman began experiencing abdominal discomfort and back pain, which was diagnosed as a distended bladder and musculoskeletal pain. She received analgesics, but subsequently experienced pain in her abdomen and right shoulder so severe that she could not move.

Approximately an hour later, the woman suffered 2 seizures. Nursing staff identified these as eclamptic seizures and called the attending physician at home. Soon after, the woman’s blood pressure began to fall and she was brought to intensive care, where she was intubated and received blood due to low hemoglobin.

Though a surgical team was assembled, the woman could not be stabilized for surgery. She died soon after. Autopsy revealed the cause of death to be intraabdominal hemorrhage due a ruptured pancreatic cyst.

The woman’s family sued the hospital, alleging that if nursing staff had contacted the physician sooner, blood administration would have begun earlier, allowing the woman to get to the operating room for surgery.

The defense argued that the woman hemorrhaged too quickly for an effective intervention to occur. Further, it maintained that the nurses’ assessment of eclamptic seizures was reasonable.

  • The jury awarded the plaintiff $12.4 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.

Cook County (Ill) Circuit Court

A few hours after an uncomplicated vaginal delivery, a 36-year-old woman began experiencing abdominal discomfort and back pain, which was diagnosed as a distended bladder and musculoskeletal pain. She received analgesics, but subsequently experienced pain in her abdomen and right shoulder so severe that she could not move.

Approximately an hour later, the woman suffered 2 seizures. Nursing staff identified these as eclamptic seizures and called the attending physician at home. Soon after, the woman’s blood pressure began to fall and she was brought to intensive care, where she was intubated and received blood due to low hemoglobin.

Though a surgical team was assembled, the woman could not be stabilized for surgery. She died soon after. Autopsy revealed the cause of death to be intraabdominal hemorrhage due a ruptured pancreatic cyst.

The woman’s family sued the hospital, alleging that if nursing staff had contacted the physician sooner, blood administration would have begun earlier, allowing the woman to get to the operating room for surgery.

The defense argued that the woman hemorrhaged too quickly for an effective intervention to occur. Further, it maintained that the nurses’ assessment of eclamptic seizures was reasonable.

  • The jury awarded the plaintiff $12.4 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.
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Was ovary removed without consent?

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<court>Buchanan County (Mo) Circuit Court</court>

A 33-year-old woman presented to a hospital with severe pain in her lower right quadrant. She had had a hysterectomy 11 years earlier due to painful adhesions; a painful right ovarian cyst 7 years prior was treated with analgesics and oral contraceptives.

An ultrasound revealed a simple cyst on the right ovary. The consulting Ob/Gyn ordered a 5-week regimen of analgesics and oral contraceptives. Symptoms persisted after the regimen’s completion, however, so the physician recommended surgery.

The following day the woman had a bilateral oophorectomy. Five days after discharge she returned to the hospital with lower abdominal pain. Testing revealed injury to her left ureter, which was leaking urine resulting in urinoma. A nephrostomy tube was inserted; she wore this with a collecting bag for the following 2 months, after which the ureter was repaired.

In suing, the woman claimed to have consented to removal of her right ovary only—not both. She noted all pain following her hysterectomy had been on her right side. Further, she claimed the physician was negligent for injuring her ureter at the time of surgery, most likely by use of a clamp.

The defendant maintained the patient wanted a bilateral oophorectomy to prevent future pain. He argued that the left ovary was diseased, and noted that at surgery it was scarred and attached to the pelvic sidewall. He denied using a clamp.

  • The first trial resulted in a hung jury. The jury in the second trial returned a defense verdict.

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.

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<court>Buchanan County (Mo) Circuit Court</court>

A 33-year-old woman presented to a hospital with severe pain in her lower right quadrant. She had had a hysterectomy 11 years earlier due to painful adhesions; a painful right ovarian cyst 7 years prior was treated with analgesics and oral contraceptives.

An ultrasound revealed a simple cyst on the right ovary. The consulting Ob/Gyn ordered a 5-week regimen of analgesics and oral contraceptives. Symptoms persisted after the regimen’s completion, however, so the physician recommended surgery.

The following day the woman had a bilateral oophorectomy. Five days after discharge she returned to the hospital with lower abdominal pain. Testing revealed injury to her left ureter, which was leaking urine resulting in urinoma. A nephrostomy tube was inserted; she wore this with a collecting bag for the following 2 months, after which the ureter was repaired.

In suing, the woman claimed to have consented to removal of her right ovary only—not both. She noted all pain following her hysterectomy had been on her right side. Further, she claimed the physician was negligent for injuring her ureter at the time of surgery, most likely by use of a clamp.

The defendant maintained the patient wanted a bilateral oophorectomy to prevent future pain. He argued that the left ovary was diseased, and noted that at surgery it was scarred and attached to the pelvic sidewall. He denied using a clamp.

  • The first trial resulted in a hung jury. The jury in the second trial returned a defense verdict.

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.

<court>Buchanan County (Mo) Circuit Court</court>

A 33-year-old woman presented to a hospital with severe pain in her lower right quadrant. She had had a hysterectomy 11 years earlier due to painful adhesions; a painful right ovarian cyst 7 years prior was treated with analgesics and oral contraceptives.

An ultrasound revealed a simple cyst on the right ovary. The consulting Ob/Gyn ordered a 5-week regimen of analgesics and oral contraceptives. Symptoms persisted after the regimen’s completion, however, so the physician recommended surgery.

The following day the woman had a bilateral oophorectomy. Five days after discharge she returned to the hospital with lower abdominal pain. Testing revealed injury to her left ureter, which was leaking urine resulting in urinoma. A nephrostomy tube was inserted; she wore this with a collecting bag for the following 2 months, after which the ureter was repaired.

In suing, the woman claimed to have consented to removal of her right ovary only—not both. She noted all pain following her hysterectomy had been on her right side. Further, she claimed the physician was negligent for injuring her ureter at the time of surgery, most likely by use of a clamp.

The defendant maintained the patient wanted a bilateral oophorectomy to prevent future pain. He argued that the left ovary was diseased, and noted that at surgery it was scarred and attached to the pelvic sidewall. He denied using a clamp.

  • The first trial resulted in a hung jury. The jury in the second trial returned a defense verdict.

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.

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Unconfirmed pregnancy: Tips on a new code

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Q When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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.

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Q When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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 When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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.

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Estradiol assessment: What’s the difference?

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Q When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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.

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Q When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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 When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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.

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Ultrasound included with D&C?

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Q I performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.

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Q I performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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 performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.

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Prevent Computer Abuse

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As I discussed last month, the rapid evolution of electronic medical records and electronic claims filing has greatly increased the role of computers in our offices, and this trend will continue for the foreseeable future, largely because the federal government has decreed that it will happen whether we like it or not.

But, of course, with progress comes new problems. As computers become more ubiquitous, computer abuse will become a larger and larger threat.

It is already a major issue in the general business world. Here are some statistics from a recent industry survey:

▸ Two-thirds of employees with Internet access admit to using it for personal diversion during working hours.

▸ At work, 30%-40% of Internet time is spent on non-work-related browsing, and 60% of all online purchases are made during working hours.

▸ Seventy percent of all Internet porn traffic occurs during the 9-5 workday.

In short, up to 40% of lost productivity can now be blamed on computer abuse.

But lost productivity isn't the only problem. Unauthorized Internet access increases vulnerability to viruses, worms, and trojans, which can shut down your network.

On top of that, an estimated 80% of computer crime, such as embezzlement and theft of intellectual property, is done by "insiders"—employees working within the victimized companies, on company time.

"Outsiders" can be a problem too. If your office runs an unsecured wireless network, anyone with even a marginal command of network mechanics can easily gain access to your practice finances, your patients' medical records—anything running on your computers.

If you have an application service provider (ASP) system, where your medical records are stored electronically on an offsite server, such potential security breaches are an even bigger issue, for both patient confidentiality and general efficiency. So it behooves you to pay close attention to how your computer network is set up and how your computers are used on your time.

Start with computer monitoring software. Several reasonably-priced programs are available. They automatically and discreetly record everything done on a computer, including Internet activity, chat rooms, instant messages, and Web sites.

Examples include Snapshot Spy (www.snapshotspy.comwww.spectorsoft.comwww.softprobe.com

Monitoring software runs quietly in the background and cannot be detected by users, but I strongly advise informing your employees that their computer use is being monitored for their safety as well as yours.

Protecting your network from unauthorized access and signal diversion is a more complicated issue. For starters, don't use the default system ID, since any hacker can find that in the user's manual. Change it to something unique—not your birthday or your pet's name. Disable "identifier broadcasting," which announces to the world that you have a wireless connection. Enable any encryption supplied with your network, and get more if you need it. (See below.) Configure your router to allow only incoming or outgoing traffic that you have approved. Depending on the complexity of your network, you may need more sophisticated protection, such as AirDefense (www.airdefense.netwww.cryptocard.comwww.lucidlink.com

It goes without saying that all of your computers, including private ones, need personal firewall software such as Zone Alarm Pro (www.zonelabs.com

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As I discussed last month, the rapid evolution of electronic medical records and electronic claims filing has greatly increased the role of computers in our offices, and this trend will continue for the foreseeable future, largely because the federal government has decreed that it will happen whether we like it or not.

But, of course, with progress comes new problems. As computers become more ubiquitous, computer abuse will become a larger and larger threat.

It is already a major issue in the general business world. Here are some statistics from a recent industry survey:

▸ Two-thirds of employees with Internet access admit to using it for personal diversion during working hours.

▸ At work, 30%-40% of Internet time is spent on non-work-related browsing, and 60% of all online purchases are made during working hours.

▸ Seventy percent of all Internet porn traffic occurs during the 9-5 workday.

In short, up to 40% of lost productivity can now be blamed on computer abuse.

But lost productivity isn't the only problem. Unauthorized Internet access increases vulnerability to viruses, worms, and trojans, which can shut down your network.

On top of that, an estimated 80% of computer crime, such as embezzlement and theft of intellectual property, is done by "insiders"—employees working within the victimized companies, on company time.

"Outsiders" can be a problem too. If your office runs an unsecured wireless network, anyone with even a marginal command of network mechanics can easily gain access to your practice finances, your patients' medical records—anything running on your computers.

If you have an application service provider (ASP) system, where your medical records are stored electronically on an offsite server, such potential security breaches are an even bigger issue, for both patient confidentiality and general efficiency. So it behooves you to pay close attention to how your computer network is set up and how your computers are used on your time.

Start with computer monitoring software. Several reasonably-priced programs are available. They automatically and discreetly record everything done on a computer, including Internet activity, chat rooms, instant messages, and Web sites.

Examples include Snapshot Spy (www.snapshotspy.comwww.spectorsoft.comwww.softprobe.com

Monitoring software runs quietly in the background and cannot be detected by users, but I strongly advise informing your employees that their computer use is being monitored for their safety as well as yours.

Protecting your network from unauthorized access and signal diversion is a more complicated issue. For starters, don't use the default system ID, since any hacker can find that in the user's manual. Change it to something unique—not your birthday or your pet's name. Disable "identifier broadcasting," which announces to the world that you have a wireless connection. Enable any encryption supplied with your network, and get more if you need it. (See below.) Configure your router to allow only incoming or outgoing traffic that you have approved. Depending on the complexity of your network, you may need more sophisticated protection, such as AirDefense (www.airdefense.netwww.cryptocard.comwww.lucidlink.com

It goes without saying that all of your computers, including private ones, need personal firewall software such as Zone Alarm Pro (www.zonelabs.com

As I discussed last month, the rapid evolution of electronic medical records and electronic claims filing has greatly increased the role of computers in our offices, and this trend will continue for the foreseeable future, largely because the federal government has decreed that it will happen whether we like it or not.

But, of course, with progress comes new problems. As computers become more ubiquitous, computer abuse will become a larger and larger threat.

It is already a major issue in the general business world. Here are some statistics from a recent industry survey:

▸ Two-thirds of employees with Internet access admit to using it for personal diversion during working hours.

▸ At work, 30%-40% of Internet time is spent on non-work-related browsing, and 60% of all online purchases are made during working hours.

▸ Seventy percent of all Internet porn traffic occurs during the 9-5 workday.

In short, up to 40% of lost productivity can now be blamed on computer abuse.

But lost productivity isn't the only problem. Unauthorized Internet access increases vulnerability to viruses, worms, and trojans, which can shut down your network.

On top of that, an estimated 80% of computer crime, such as embezzlement and theft of intellectual property, is done by "insiders"—employees working within the victimized companies, on company time.

"Outsiders" can be a problem too. If your office runs an unsecured wireless network, anyone with even a marginal command of network mechanics can easily gain access to your practice finances, your patients' medical records—anything running on your computers.

If you have an application service provider (ASP) system, where your medical records are stored electronically on an offsite server, such potential security breaches are an even bigger issue, for both patient confidentiality and general efficiency. So it behooves you to pay close attention to how your computer network is set up and how your computers are used on your time.

Start with computer monitoring software. Several reasonably-priced programs are available. They automatically and discreetly record everything done on a computer, including Internet activity, chat rooms, instant messages, and Web sites.

Examples include Snapshot Spy (www.snapshotspy.comwww.spectorsoft.comwww.softprobe.com

Monitoring software runs quietly in the background and cannot be detected by users, but I strongly advise informing your employees that their computer use is being monitored for their safety as well as yours.

Protecting your network from unauthorized access and signal diversion is a more complicated issue. For starters, don't use the default system ID, since any hacker can find that in the user's manual. Change it to something unique—not your birthday or your pet's name. Disable "identifier broadcasting," which announces to the world that you have a wireless connection. Enable any encryption supplied with your network, and get more if you need it. (See below.) Configure your router to allow only incoming or outgoing traffic that you have approved. Depending on the complexity of your network, you may need more sophisticated protection, such as AirDefense (www.airdefense.netwww.cryptocard.comwww.lucidlink.com

It goes without saying that all of your computers, including private ones, need personal firewall software such as Zone Alarm Pro (www.zonelabs.com

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Could preterm twins have been saved?

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US District Court

Within in 48 hours of birth, twin boys born at 24 weeks’ gestation died due to respiratory distress syndrome.

The mother claimed negligence, alleging that the obstetrician should have:

  • performed a urinalysis and urine culture at her first prenatal visit,
  • ordered a urinalysis and therapy for asymptomatic bacteria detected on urine dipstick testing,
  • assessed her for preterm labor during an office visit, and
  • provided medical therapy to prevent preterm birth.
The physician argued that premature delivery could not have been prevented.

  • The jury awarded the plaintiff $225,000.
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.
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Within in 48 hours of birth, twin boys born at 24 weeks’ gestation died due to respiratory distress syndrome.

The mother claimed negligence, alleging that the obstetrician should have:

  • performed a urinalysis and urine culture at her first prenatal visit,
  • ordered a urinalysis and therapy for asymptomatic bacteria detected on urine dipstick testing,
  • assessed her for preterm labor during an office visit, and
  • provided medical therapy to prevent preterm birth.
The physician argued that premature delivery could not have been prevented.

  • The jury awarded the plaintiff $225,000.
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.

US District Court

Within in 48 hours of birth, twin boys born at 24 weeks’ gestation died due to respiratory distress syndrome.

The mother claimed negligence, alleging that the obstetrician should have:

  • performed a urinalysis and urine culture at her first prenatal visit,
  • ordered a urinalysis and therapy for asymptomatic bacteria detected on urine dipstick testing,
  • assessed her for preterm labor during an office visit, and
  • provided medical therapy to prevent preterm birth.
The physician argued that premature delivery could not have been prevented.

  • The jury awarded the plaintiff $225,000.
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.
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Cesarean declined, stillbirth follows

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Undisclosed venue (Va)

Two weeks past her due date and 12 hours before a scheduled induction, a woman with a prior cesarean presented to a hospital reporting decreased fetal movement.

On fetal monitoring, the child’s heart rate was nonreactive with decreased variability. When examination showed the woman’s cervix was closed, the obstetrician offered a cesarean section. The woman refused, opting for a trial of labor. A cervical ripening agent was administered via suppository.

When, 5 hours later, fetal monitoring showed 2 late decelerations but the cervix remained undilated, the physician once again offered a cesarean. The woman again declined.

An epidural was administered 2.5 hours later, after which the child’s heart rate dropped sharply. Sonography soon after revealed no fetal heart rate. An emergency cesarean was performed, but the child was stillborn.

The woman sued, claiming a cesarean should have been performed after the first signs of fetal distress. Had delivery occurred any time prior to the 2 late decelerations, she alleged, the child would have been born alive.

The defendant noted that the woman twice declined a cesarean section.

  • The case settled for $375,000.
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.
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Two weeks past her due date and 12 hours before a scheduled induction, a woman with a prior cesarean presented to a hospital reporting decreased fetal movement.

On fetal monitoring, the child’s heart rate was nonreactive with decreased variability. When examination showed the woman’s cervix was closed, the obstetrician offered a cesarean section. The woman refused, opting for a trial of labor. A cervical ripening agent was administered via suppository.

When, 5 hours later, fetal monitoring showed 2 late decelerations but the cervix remained undilated, the physician once again offered a cesarean. The woman again declined.

An epidural was administered 2.5 hours later, after which the child’s heart rate dropped sharply. Sonography soon after revealed no fetal heart rate. An emergency cesarean was performed, but the child was stillborn.

The woman sued, claiming a cesarean should have been performed after the first signs of fetal distress. Had delivery occurred any time prior to the 2 late decelerations, she alleged, the child would have been born alive.

The defendant noted that the woman twice declined a cesarean section.

  • The case settled for $375,000.
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 venue (Va)

Two weeks past her due date and 12 hours before a scheduled induction, a woman with a prior cesarean presented to a hospital reporting decreased fetal movement.

On fetal monitoring, the child’s heart rate was nonreactive with decreased variability. When examination showed the woman’s cervix was closed, the obstetrician offered a cesarean section. The woman refused, opting for a trial of labor. A cervical ripening agent was administered via suppository.

When, 5 hours later, fetal monitoring showed 2 late decelerations but the cervix remained undilated, the physician once again offered a cesarean. The woman again declined.

An epidural was administered 2.5 hours later, after which the child’s heart rate dropped sharply. Sonography soon after revealed no fetal heart rate. An emergency cesarean was performed, but the child was stillborn.

The woman sued, claiming a cesarean should have been performed after the first signs of fetal distress. Had delivery occurred any time prior to the 2 late decelerations, she alleged, the child would have been born alive.

The defendant noted that the woman twice declined a cesarean section.

  • The case settled for $375,000.
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.
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