Managing Your Practice

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

Cook County (Ill) Circuit Court

A 47-year-old woman presented with menorrhagia, for which her Ob/Gyn prescribed oral contraceptives (OCs). Approximately 1 month later, the woman suffered a cerebral hemorrhage that resulted in aphasia.

In suing, the woman contended that, as per the standard of care, she should have been prescribed progesterone—not OCs—due to a family history of strokes.

The defendant, while aware of the patient’s history, believed the benefits of OCs outweighed the risks.

• The jury awarded the plaintiff $545,000.
  

Cook County (Ill) Circuit Court

A 47-year-old woman presented with menorrhagia, for which her Ob/Gyn prescribed oral contraceptives (OCs). Approximately 1 month later, the woman suffered a cerebral hemorrhage that resulted in aphasia.

In suing, the woman contended that, as per the standard of care, she should have been prescribed progesterone—not OCs—due to a family history of strokes.

The defendant, while aware of the patient’s history, believed the benefits of OCs outweighed the risks.

• The jury awarded the plaintiff $545,000.
  

Cook County (Ill) Circuit Court

A 47-year-old woman presented with menorrhagia, for which her Ob/Gyn prescribed oral contraceptives (OCs). Approximately 1 month later, the woman suffered a cerebral hemorrhage that resulted in aphasia.

In suing, the woman contended that, as per the standard of care, she should have been prescribed progesterone—not OCs—due to a family history of strokes.

The defendant, while aware of the patient’s history, believed the benefits of OCs outweighed the risks.

• The jury awarded the plaintiff $545,000.
  

<court>Queens County (NY) Supreme Court</court>

A 21-year-old woman presented with complaints of severe abdominal pain and fainting. Hospital residents determined she was 5 weeks pregnant. After informing the clinicians she had received a birth-control shot 5 to 6 weeks earlier, she was admitted for additional testing. During this time her beta-human chorionic gonadotropin (β-HCG) was noted as rising.

Following a dilation and curettage procedure conducted 2 days after admission, physicians concluded the patient had miscarried. A pathology report issued 4 days later, however, noted no pregnancy tissue in the woman’s uterus. No additional studies were ordered and the woman was released.

Four days later, the woman presented to another hospital with a fallopian tube ruptured beyond repair, and underwent a salpingectomy.

In suing, the plaintiff claimed that information obtained during her hospital stay clearly pointed to an ectopic pregnancy—specifically, the slowness with which her β-HCG levels were rising and the absence of pregnancy tissue in her uterus. Had the ectopic pregnancy been diagnosed, she argued, the injury to her fallopian tube would have been discovered earlier, when it could have been repaired laparoscopically, protecting her fertility.

Further, the woman contended that during her stay she suffered undiagnosed internal bleeding that may have caused damage to her remaining fallopian tube, thus cutting her chances of achieving pregnancy naturally by more than half.

One of the 2 defendant attending physicians claimed she was not in any way involved with the admission or care of the patient; as a result, action against her was subsequently dropped. The second physician maintained she was never informed of the pathology results.

• The case settled for $500,000, split between the defendant hospital and physician.

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>Queens County (NY) Supreme Court</court>

A 21-year-old woman presented with complaints of severe abdominal pain and fainting. Hospital residents determined she was 5 weeks pregnant. After informing the clinicians she had received a birth-control shot 5 to 6 weeks earlier, she was admitted for additional testing. During this time her beta-human chorionic gonadotropin (β-HCG) was noted as rising.

Following a dilation and curettage procedure conducted 2 days after admission, physicians concluded the patient had miscarried. A pathology report issued 4 days later, however, noted no pregnancy tissue in the woman’s uterus. No additional studies were ordered and the woman was released.

Four days later, the woman presented to another hospital with a fallopian tube ruptured beyond repair, and underwent a salpingectomy.

In suing, the plaintiff claimed that information obtained during her hospital stay clearly pointed to an ectopic pregnancy—specifically, the slowness with which her β-HCG levels were rising and the absence of pregnancy tissue in her uterus. Had the ectopic pregnancy been diagnosed, she argued, the injury to her fallopian tube would have been discovered earlier, when it could have been repaired laparoscopically, protecting her fertility.

Further, the woman contended that during her stay she suffered undiagnosed internal bleeding that may have caused damage to her remaining fallopian tube, thus cutting her chances of achieving pregnancy naturally by more than half.

One of the 2 defendant attending physicians claimed she was not in any way involved with the admission or care of the patient; as a result, action against her was subsequently dropped. The second physician maintained she was never informed of the pathology results.

• The case settled for $500,000, split between the defendant hospital and physician.

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>Queens County (NY) Supreme Court</court>

A 21-year-old woman presented with complaints of severe abdominal pain and fainting. Hospital residents determined she was 5 weeks pregnant. After informing the clinicians she had received a birth-control shot 5 to 6 weeks earlier, she was admitted for additional testing. During this time her beta-human chorionic gonadotropin (β-HCG) was noted as rising.

Following a dilation and curettage procedure conducted 2 days after admission, physicians concluded the patient had miscarried. A pathology report issued 4 days later, however, noted no pregnancy tissue in the woman’s uterus. No additional studies were ordered and the woman was released.

Four days later, the woman presented to another hospital with a fallopian tube ruptured beyond repair, and underwent a salpingectomy.

In suing, the plaintiff claimed that information obtained during her hospital stay clearly pointed to an ectopic pregnancy—specifically, the slowness with which her β-HCG levels were rising and the absence of pregnancy tissue in her uterus. Had the ectopic pregnancy been diagnosed, she argued, the injury to her fallopian tube would have been discovered earlier, when it could have been repaired laparoscopically, protecting her fertility.

Further, the woman contended that during her stay she suffered undiagnosed internal bleeding that may have caused damage to her remaining fallopian tube, thus cutting her chances of achieving pregnancy naturally by more than half.

One of the 2 defendant attending physicians claimed she was not in any way involved with the admission or care of the patient; as a result, action against her was subsequently dropped. The second physician maintained she was never informed of the pathology results.

• The case settled for $500,000, split between the defendant hospital and physician.

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.

Contra Costa County (Calif) Superior Court

Upon admission for induction of labor, a 31-year-old gravida at 41 weeks’ gestation was given misoprostol, at 8 pm. At 5 am, the nurse began oxytocin based on the Ob/Gyn’s orders.

At 6:30 am, after examining the patient, the doctor diagnosed pregnancy-induced hypertension, ordered magnesium sulfate, and performed an artificial rupture of membranes. The physician then left the hospital to return to his office.

At 1:50 pm, fetal monitoring strips displayed decreased variability. Fifty-five minutes later, the oxytocin dosage was increased.

At 5:15 pm, the doctor returned to find the mother fully dilated and the infant in occiput-posterior position. Attempts to rotate the head proved unsuccessful; thus at 6 pm the Ob/Gyn opted for a cesarean delivery. A monitor attached in the operating room showed a fetal heart rate in the sixties.

At 6:23 pm, the child was born and had Apgar scores of 1, 3, and 4. A blood culture revealed Group D strep infection and a blood gas at 50 minutes of age showed metabolic acidosis. The child was later diagnosed with cerebral palsy and at age 3 was profoundly disabled.

In suing, the plaintiffs alleged that the combination of increased oxytocin, a nonreassuring fetal heart rate, and pregnancy-induced hypertension led to acute asphyxia at approximately 5:50 pm. Had cesarean delivery been initiated prior to this time, they contended, the child would have been normal at birth.

The defendant hospital maintained the oxytocin increases were reasonable, and claimed the fetal monitoring strips were reassuring with good variability for a woman receiving epidural medication and magnesium sulfate.

According to the defendant physician, computed tomography imaging showed that the child’s brain injury was sudden and abrupt, indicating acute cord compression. It was argued that this compression was unpredictable, and that the child’s ability to tolerate it was compromised due to the presence of severe Group D strep, as evidenced by her metabolic acidosis.

• The jury returned a defense verdict for the Ob/Gyn. They returned a gross verdict of $59.3 million against the defendant hospital. The present cash value of the gross verdict was determined to be $6.4 million for future medical costs plus $904,000 for future loss of earning capacity.
  

Contra Costa County (Calif) Superior Court

Upon admission for induction of labor, a 31-year-old gravida at 41 weeks’ gestation was given misoprostol, at 8 pm. At 5 am, the nurse began oxytocin based on the Ob/Gyn’s orders.

At 6:30 am, after examining the patient, the doctor diagnosed pregnancy-induced hypertension, ordered magnesium sulfate, and performed an artificial rupture of membranes. The physician then left the hospital to return to his office.

At 1:50 pm, fetal monitoring strips displayed decreased variability. Fifty-five minutes later, the oxytocin dosage was increased.

At 5:15 pm, the doctor returned to find the mother fully dilated and the infant in occiput-posterior position. Attempts to rotate the head proved unsuccessful; thus at 6 pm the Ob/Gyn opted for a cesarean delivery. A monitor attached in the operating room showed a fetal heart rate in the sixties.

At 6:23 pm, the child was born and had Apgar scores of 1, 3, and 4. A blood culture revealed Group D strep infection and a blood gas at 50 minutes of age showed metabolic acidosis. The child was later diagnosed with cerebral palsy and at age 3 was profoundly disabled.

In suing, the plaintiffs alleged that the combination of increased oxytocin, a nonreassuring fetal heart rate, and pregnancy-induced hypertension led to acute asphyxia at approximately 5:50 pm. Had cesarean delivery been initiated prior to this time, they contended, the child would have been normal at birth.

The defendant hospital maintained the oxytocin increases were reasonable, and claimed the fetal monitoring strips were reassuring with good variability for a woman receiving epidural medication and magnesium sulfate.

According to the defendant physician, computed tomography imaging showed that the child’s brain injury was sudden and abrupt, indicating acute cord compression. It was argued that this compression was unpredictable, and that the child’s ability to tolerate it was compromised due to the presence of severe Group D strep, as evidenced by her metabolic acidosis.

• The jury returned a defense verdict for the Ob/Gyn. They returned a gross verdict of $59.3 million against the defendant hospital. The present cash value of the gross verdict was determined to be $6.4 million for future medical costs plus $904,000 for future loss of earning capacity.
  

Contra Costa County (Calif) Superior Court

Upon admission for induction of labor, a 31-year-old gravida at 41 weeks’ gestation was given misoprostol, at 8 pm. At 5 am, the nurse began oxytocin based on the Ob/Gyn’s orders.

At 6:30 am, after examining the patient, the doctor diagnosed pregnancy-induced hypertension, ordered magnesium sulfate, and performed an artificial rupture of membranes. The physician then left the hospital to return to his office.

At 1:50 pm, fetal monitoring strips displayed decreased variability. Fifty-five minutes later, the oxytocin dosage was increased.

At 5:15 pm, the doctor returned to find the mother fully dilated and the infant in occiput-posterior position. Attempts to rotate the head proved unsuccessful; thus at 6 pm the Ob/Gyn opted for a cesarean delivery. A monitor attached in the operating room showed a fetal heart rate in the sixties.

At 6:23 pm, the child was born and had Apgar scores of 1, 3, and 4. A blood culture revealed Group D strep infection and a blood gas at 50 minutes of age showed metabolic acidosis. The child was later diagnosed with cerebral palsy and at age 3 was profoundly disabled.

In suing, the plaintiffs alleged that the combination of increased oxytocin, a nonreassuring fetal heart rate, and pregnancy-induced hypertension led to acute asphyxia at approximately 5:50 pm. Had cesarean delivery been initiated prior to this time, they contended, the child would have been normal at birth.

The defendant hospital maintained the oxytocin increases were reasonable, and claimed the fetal monitoring strips were reassuring with good variability for a woman receiving epidural medication and magnesium sulfate.

According to the defendant physician, computed tomography imaging showed that the child’s brain injury was sudden and abrupt, indicating acute cord compression. It was argued that this compression was unpredictable, and that the child’s ability to tolerate it was compromised due to the presence of severe Group D strep, as evidenced by her metabolic acidosis.

• The jury returned a defense verdict for the Ob/Gyn. They returned a gross verdict of $59.3 million against the defendant hospital. The present cash value of the gross verdict was determined to be $6.4 million for future medical costs plus $904,000 for future loss of earning capacity.
  

Middlesex County (NJ) Superior Court

A child suffered Erb’s palsy following shoulder dystocia encountered during delivery. As a result, he cannot fully extend, rotate, or raise his right arm, which is 1 inch shorter than his left.

The defendant Ob/Gyn contended that, in an effort to dislodge the shoulder, he applied gentle downward traction with his fingers. He also argued that an intrauterine event led to the injury.

However, videotape of the birth taken by the plaintiff’s grandmother showed the physician pushing down on the child’s head with both hands, rotating the head, then applying additional traction. After the infant’s birth, the physician is shown raising and releasing the affected arm, which fell limply to the child’s side.

This footage conflicted with the physician’s notes, which did not indicate the second application of traction or the examination of the right arm.

The plaintiff maintained that excessive force at birth was responsible for the Erb’s palsy and sequelae.

• The jury awarded the plaintiff $1.05 million.
  

Middlesex County (NJ) Superior Court

A child suffered Erb’s palsy following shoulder dystocia encountered during delivery. As a result, he cannot fully extend, rotate, or raise his right arm, which is 1 inch shorter than his left.

The defendant Ob/Gyn contended that, in an effort to dislodge the shoulder, he applied gentle downward traction with his fingers. He also argued that an intrauterine event led to the injury.

However, videotape of the birth taken by the plaintiff’s grandmother showed the physician pushing down on the child’s head with both hands, rotating the head, then applying additional traction. After the infant’s birth, the physician is shown raising and releasing the affected arm, which fell limply to the child’s side.

This footage conflicted with the physician’s notes, which did not indicate the second application of traction or the examination of the right arm.

The plaintiff maintained that excessive force at birth was responsible for the Erb’s palsy and sequelae.

• The jury awarded the plaintiff $1.05 million.
  

Middlesex County (NJ) Superior Court

A child suffered Erb’s palsy following shoulder dystocia encountered during delivery. As a result, he cannot fully extend, rotate, or raise his right arm, which is 1 inch shorter than his left.

The defendant Ob/Gyn contended that, in an effort to dislodge the shoulder, he applied gentle downward traction with his fingers. He also argued that an intrauterine event led to the injury.

However, videotape of the birth taken by the plaintiff’s grandmother showed the physician pushing down on the child’s head with both hands, rotating the head, then applying additional traction. After the infant’s birth, the physician is shown raising and releasing the affected arm, which fell limply to the child’s side.

This footage conflicted with the physician’s notes, which did not indicate the second application of traction or the examination of the right arm.

The plaintiff maintained that excessive force at birth was responsible for the Erb’s palsy and sequelae.

• The jury awarded the plaintiff $1.05 million.
  

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.