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Mother dies after cesarean: Was overdose to blame?
<court>Montgomery County (Ohio) Court of Common Pleas</court>
At 31 weeks’ gestation, a 31-year-old gravida reported to her obstetrician’s office with complaints of vomiting. In the absence of the doctor, who was on vacation, a nurse administered hydroxyzine and promethazine and sent the woman home.
Three days later the woman again presented, still reporting vomiting. The since-returned physician ordered immediate transfer to the hospital, where he delivered a healthy male infant via emergency cesarean. He prescribed 25 mg of meperidine for pain.
Shortly after hospital staff loaded a 300-mg meperidine pack into a patient-controlled analgesia machine, the woman went into respiratory arrest. Though resuscitated, she suffered severe brain damage.
The woman was also found to have fatty liver disease, and thus underwent a successful liver transplant. A week later, however, she died as a result of the brain injury.
In suing, the woman’s family claimed the woman’s hypoxic event stemmed from meperidine overdose. They also argued that the nurse was negligent in administering hydroxyzine and promethazine without the doctor’s consent.
The defense noted that the nurse had a standing order from the physician to treat pregnancy-related emesis with hydroxyzine and promethazine. They also argued that the liver disease, not meperidine overdose, was responsible for the respiratory event.
- The jury 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>Montgomery County (Ohio) Court of Common Pleas</court>
At 31 weeks’ gestation, a 31-year-old gravida reported to her obstetrician’s office with complaints of vomiting. In the absence of the doctor, who was on vacation, a nurse administered hydroxyzine and promethazine and sent the woman home.
Three days later the woman again presented, still reporting vomiting. The since-returned physician ordered immediate transfer to the hospital, where he delivered a healthy male infant via emergency cesarean. He prescribed 25 mg of meperidine for pain.
Shortly after hospital staff loaded a 300-mg meperidine pack into a patient-controlled analgesia machine, the woman went into respiratory arrest. Though resuscitated, she suffered severe brain damage.
The woman was also found to have fatty liver disease, and thus underwent a successful liver transplant. A week later, however, she died as a result of the brain injury.
In suing, the woman’s family claimed the woman’s hypoxic event stemmed from meperidine overdose. They also argued that the nurse was negligent in administering hydroxyzine and promethazine without the doctor’s consent.
The defense noted that the nurse had a standing order from the physician to treat pregnancy-related emesis with hydroxyzine and promethazine. They also argued that the liver disease, not meperidine overdose, was responsible for the respiratory event.
- The jury 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>Montgomery County (Ohio) Court of Common Pleas</court>
At 31 weeks’ gestation, a 31-year-old gravida reported to her obstetrician’s office with complaints of vomiting. In the absence of the doctor, who was on vacation, a nurse administered hydroxyzine and promethazine and sent the woman home.
Three days later the woman again presented, still reporting vomiting. The since-returned physician ordered immediate transfer to the hospital, where he delivered a healthy male infant via emergency cesarean. He prescribed 25 mg of meperidine for pain.
Shortly after hospital staff loaded a 300-mg meperidine pack into a patient-controlled analgesia machine, the woman went into respiratory arrest. Though resuscitated, she suffered severe brain damage.
The woman was also found to have fatty liver disease, and thus underwent a successful liver transplant. A week later, however, she died as a result of the brain injury.
In suing, the woman’s family claimed the woman’s hypoxic event stemmed from meperidine overdose. They also argued that the nurse was negligent in administering hydroxyzine and promethazine without the doctor’s consent.
The defense noted that the nurse had a standing order from the physician to treat pregnancy-related emesis with hydroxyzine and promethazine. They also argued that the liver disease, not meperidine overdose, was responsible for the respiratory event.
- The jury 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.
Was decreased fetal movement mishandled?
Five weeks before her due date, a 28-year-old gravida reported decreased fetal movement and no activity during a kick test. A physician performed a biophysical profile and noted a score of 8 out of 10 with a nonreactive stress test. The woman was sent home and advised to inform the group of any additional changes in fetal movement.
She contacted the group 5 days later, again noting an absence of fetal movement. At the hospital, another physician in the group was unable to detect a fetal heart rate. Another 3 and a half hours passed before the doctor delivered the child by cesarean section.
Though born with an Apgar score of 9, the child was hypoglycemic and acidotic, and later diagnosed with periventricular leukomalacia. Age 6 at the time of the trial, she suffers from seizures, spastic quadriparesis, and cortical blindness.
The plaintiff alleged that the first physician misread the biophysical profile and the second physician was negligent in delaying cesarean delivery after failing to detect a heartbeat. All 3 group members were cited for not responding appropriately to the mother’s initial complaint of decreased fetal movement.
The defendants maintained the biophysical profile was correct. They argued that, in light of the high Apgar score at birth, the child’s condition likely stemmed from a chronic condition precipitated by placental insufficiency several weeks before delivery.
- The jury awarded the plaintiff $111.7 million. A high/low agreement reached prior to the verdict reduced the award to $6 million.
Five weeks before her due date, a 28-year-old gravida reported decreased fetal movement and no activity during a kick test. A physician performed a biophysical profile and noted a score of 8 out of 10 with a nonreactive stress test. The woman was sent home and advised to inform the group of any additional changes in fetal movement.
She contacted the group 5 days later, again noting an absence of fetal movement. At the hospital, another physician in the group was unable to detect a fetal heart rate. Another 3 and a half hours passed before the doctor delivered the child by cesarean section.
Though born with an Apgar score of 9, the child was hypoglycemic and acidotic, and later diagnosed with periventricular leukomalacia. Age 6 at the time of the trial, she suffers from seizures, spastic quadriparesis, and cortical blindness.
The plaintiff alleged that the first physician misread the biophysical profile and the second physician was negligent in delaying cesarean delivery after failing to detect a heartbeat. All 3 group members were cited for not responding appropriately to the mother’s initial complaint of decreased fetal movement.
The defendants maintained the biophysical profile was correct. They argued that, in light of the high Apgar score at birth, the child’s condition likely stemmed from a chronic condition precipitated by placental insufficiency several weeks before delivery.
- The jury awarded the plaintiff $111.7 million. A high/low agreement reached prior to the verdict reduced the award to $6 million.
Five weeks before her due date, a 28-year-old gravida reported decreased fetal movement and no activity during a kick test. A physician performed a biophysical profile and noted a score of 8 out of 10 with a nonreactive stress test. The woman was sent home and advised to inform the group of any additional changes in fetal movement.
She contacted the group 5 days later, again noting an absence of fetal movement. At the hospital, another physician in the group was unable to detect a fetal heart rate. Another 3 and a half hours passed before the doctor delivered the child by cesarean section.
Though born with an Apgar score of 9, the child was hypoglycemic and acidotic, and later diagnosed with periventricular leukomalacia. Age 6 at the time of the trial, she suffers from seizures, spastic quadriparesis, and cortical blindness.
The plaintiff alleged that the first physician misread the biophysical profile and the second physician was negligent in delaying cesarean delivery after failing to detect a heartbeat. All 3 group members were cited for not responding appropriately to the mother’s initial complaint of decreased fetal movement.
The defendants maintained the biophysical profile was correct. They argued that, in light of the high Apgar score at birth, the child’s condition likely stemmed from a chronic condition precipitated by placental insufficiency several weeks before delivery.
- The jury awarded the plaintiff $111.7 million. A high/low agreement reached prior to the verdict reduced the award to $6 million.
Brain damage follows induction for wrongly suspected macrosomia
Suspecting macrosomia severe enough to impede normal vaginal delivery, an obstetrician induced early labor, using forceps to deliver the infant.
At birth, however, the child weighed just 6 lbs and suffered severe brain damage. He spent the following 3 weeks in the neonatal intensive care unit, and subsequently underwent 14 surgeries to his brain and spine. He requires constant care due to severe physical and neurologic impairment.
The plaintiff claimed the physician was negligent in inducing early labor and used an improper forceps technique known to be associated with a higher risk of brain damage.
The defense maintained the child’s injuries were congenital.
- A jury awarded the plaintiff $63 million.
Suspecting macrosomia severe enough to impede normal vaginal delivery, an obstetrician induced early labor, using forceps to deliver the infant.
At birth, however, the child weighed just 6 lbs and suffered severe brain damage. He spent the following 3 weeks in the neonatal intensive care unit, and subsequently underwent 14 surgeries to his brain and spine. He requires constant care due to severe physical and neurologic impairment.
The plaintiff claimed the physician was negligent in inducing early labor and used an improper forceps technique known to be associated with a higher risk of brain damage.
The defense maintained the child’s injuries were congenital.
- A jury awarded the plaintiff $63 million.
Suspecting macrosomia severe enough to impede normal vaginal delivery, an obstetrician induced early labor, using forceps to deliver the infant.
At birth, however, the child weighed just 6 lbs and suffered severe brain damage. He spent the following 3 weeks in the neonatal intensive care unit, and subsequently underwent 14 surgeries to his brain and spine. He requires constant care due to severe physical and neurologic impairment.
The plaintiff claimed the physician was negligent in inducing early labor and used an improper forceps technique known to be associated with a higher risk of brain damage.
The defense maintained the child’s injuries were congenital.
- A jury awarded the plaintiff $63 million.
Diagnostic laparoscopy leads to bowel injury
Due to complaints of crural pain, a 38-year-old woman with a history of uterine fibroids underwent diagnostic laparoscopy; she was discharged that day.
She returned to the hospital via ambulance 2 days later, and was diagnosed with acute peritonitis. It was revealed that she had suffered a bowel perforation during the laparoscopy.
In suing, the woman claimed that her surgical history—3 prior abdominal procedures—contraindicated the laparoscopy.
The defense maintained that the procedure was appropriate given the circumstances, and that bowel perforation is a known complication.
- The jury returned a defense verdict.
Due to complaints of crural pain, a 38-year-old woman with a history of uterine fibroids underwent diagnostic laparoscopy; she was discharged that day.
She returned to the hospital via ambulance 2 days later, and was diagnosed with acute peritonitis. It was revealed that she had suffered a bowel perforation during the laparoscopy.
In suing, the woman claimed that her surgical history—3 prior abdominal procedures—contraindicated the laparoscopy.
The defense maintained that the procedure was appropriate given the circumstances, and that bowel perforation is a known complication.
- The jury returned a defense verdict.
Due to complaints of crural pain, a 38-year-old woman with a history of uterine fibroids underwent diagnostic laparoscopy; she was discharged that day.
She returned to the hospital via ambulance 2 days later, and was diagnosed with acute peritonitis. It was revealed that she had suffered a bowel perforation during the laparoscopy.
In suing, the woman claimed that her surgical history—3 prior abdominal procedures—contraindicated the laparoscopy.
The defense maintained that the procedure was appropriate given the circumstances, and that bowel perforation is a known complication.
- The jury returned a defense verdict.
Trocar use blamed for bowel perforation
A 32-year-old woman underwent laparoscopy for the treatment of endometriosis. During the course of surgery, a trocar caused a 5-mm perforation in the woman’s bowel. A general surgeon successfully repaired the injury, leaving a 3- to 4-inch scar on her abdomen.
In suing, the patient claimed that the defendant should have used a Veress needle instead of a trocar to reduce the risk of bowel injury.
The defense maintained either instrument was appropriate, and noted that such injury is a known complication of the procedure.
- The court directed a defense verdict.
A 32-year-old woman underwent laparoscopy for the treatment of endometriosis. During the course of surgery, a trocar caused a 5-mm perforation in the woman’s bowel. A general surgeon successfully repaired the injury, leaving a 3- to 4-inch scar on her abdomen.
In suing, the patient claimed that the defendant should have used a Veress needle instead of a trocar to reduce the risk of bowel injury.
The defense maintained either instrument was appropriate, and noted that such injury is a known complication of the procedure.
- The court directed a defense verdict.
A 32-year-old woman underwent laparoscopy for the treatment of endometriosis. During the course of surgery, a trocar caused a 5-mm perforation in the woman’s bowel. A general surgeon successfully repaired the injury, leaving a 3- to 4-inch scar on her abdomen.
In suing, the patient claimed that the defendant should have used a Veress needle instead of a trocar to reduce the risk of bowel injury.
The defense maintained either instrument was appropriate, and noted that such injury is a known complication of the procedure.
- The court directed a defense verdict.
D&C, fetal death follow missed pregnancy
Due to a missed period, a woman presented to her Ob/Gyn, who conducted an ultrasound. He diagnosed a blighted ovum and ordered no further tests. Per his recommendation, the woman underwent a D&C procedure.
Two weeks later, the woman delivered a deceased 3-inch fetus. A second D&C was required to remove the remaining products of conception. The plaintiffs sued, alleging emotional distress. The physician did not deny negligence, but questioned the level of distress the incident caused.
- The jury awarded the plaintiffs $220,000.
Due to a missed period, a woman presented to her Ob/Gyn, who conducted an ultrasound. He diagnosed a blighted ovum and ordered no further tests. Per his recommendation, the woman underwent a D&C procedure.
Two weeks later, the woman delivered a deceased 3-inch fetus. A second D&C was required to remove the remaining products of conception. The plaintiffs sued, alleging emotional distress. The physician did not deny negligence, but questioned the level of distress the incident caused.
- The jury awarded the plaintiffs $220,000.
Due to a missed period, a woman presented to her Ob/Gyn, who conducted an ultrasound. He diagnosed a blighted ovum and ordered no further tests. Per his recommendation, the woman underwent a D&C procedure.
Two weeks later, the woman delivered a deceased 3-inch fetus. A second D&C was required to remove the remaining products of conception. The plaintiffs sued, alleging emotional distress. The physician did not deny negligence, but questioned the level of distress the incident caused.
- The jury awarded the plaintiffs $220,000.
Did delayed cesarean cause cerebral palsy in breech twin?
<court>Summit County (Ohio) Common Pleas Court</court>
Upon discovering a breech presentation for the second fetus in a set of twins, an obstetrician attempted to rotate the infant for a vaginal delivery. In the process, the child’s umbilical cord wrapped around his neck, causing heart-rate decelerations.
Nineteen minutes passed before the child was delivered by cesarean section, by which time he had suffered severe anoxia leading to cerebral palsy.
The infant plaintiff claimed the delay in cesarean delivery led to his injuries.
The physician maintained proper care was administered, and that the child’s injuries were known risks of breech birth.
- The jury awarded the plaintiff $3.3 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.
<court>Summit County (Ohio) Common Pleas Court</court>
Upon discovering a breech presentation for the second fetus in a set of twins, an obstetrician attempted to rotate the infant for a vaginal delivery. In the process, the child’s umbilical cord wrapped around his neck, causing heart-rate decelerations.
Nineteen minutes passed before the child was delivered by cesarean section, by which time he had suffered severe anoxia leading to cerebral palsy.
The infant plaintiff claimed the delay in cesarean delivery led to his injuries.
The physician maintained proper care was administered, and that the child’s injuries were known risks of breech birth.
- The jury awarded the plaintiff $3.3 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.
<court>Summit County (Ohio) Common Pleas Court</court>
Upon discovering a breech presentation for the second fetus in a set of twins, an obstetrician attempted to rotate the infant for a vaginal delivery. In the process, the child’s umbilical cord wrapped around his neck, causing heart-rate decelerations.
Nineteen minutes passed before the child was delivered by cesarean section, by which time he had suffered severe anoxia leading to cerebral palsy.
The infant plaintiff claimed the delay in cesarean delivery led to his injuries.
The physician maintained proper care was administered, and that the child’s injuries were known risks of breech birth.
- The jury awarded the plaintiff $3.3 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.
Replacing eroded sling mesh
Obstetric ultrasound with no maternal evaluation
<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).
For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)
My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.
<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.
The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.
Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.
Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.
Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.
<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).
For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)
My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.
<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.
The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.
Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.
Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.
Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.
<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).
For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)
My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.
<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.
The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.
Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.
Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.
Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.
14-day 5-FU application: Reimbursement unlikely
If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).
They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.
You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?
If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).
They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.
You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?
If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).
They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.
You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?