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The extra effort of transvaginal injection
CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.
CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.
CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.
Bowel perforation follows fetal demise, D&E
After contracting Parvovirus, a 36-year-old woman suffered fetal demise at 23 weeks’ gestation. Cervical ripening was begun in preparation for a dilation and evacuation (D&E) of the fetal remains. The physician intended to continue this ripening the following morning, but the woman developed a fever and returned to the hospital later that evening.
The physician opted to conduct the D&E that night, but in the course of surgery perforated the woman’s uterus and delivered the bowel vaginally. As a result, the patient underwent a 5-hour procedure consisting of a hysterectomy with unilateral salpingo-oophorectomy, bowel resection, and colostomy.
The woman sued, claiming the surgeon was negligent in injuring her bowel. She further alleged lack of informed consent and improper preparation of the cervix. She argued that in addition to sterility and vaginal scarring, she suffers urinary and bowel incontinence. She maintained that resultant psychological injuries, psychosexual dysfunction, and physiological difficulties have led to problems in her sexual relationship with her husband.
The defense noted that the injuries were known complications of the D&E procedure—a medically necessary intervention. They maintained that sound clinical judgment was exercised at all times.
- The jury returned a defense verdict.
After contracting Parvovirus, a 36-year-old woman suffered fetal demise at 23 weeks’ gestation. Cervical ripening was begun in preparation for a dilation and evacuation (D&E) of the fetal remains. The physician intended to continue this ripening the following morning, but the woman developed a fever and returned to the hospital later that evening.
The physician opted to conduct the D&E that night, but in the course of surgery perforated the woman’s uterus and delivered the bowel vaginally. As a result, the patient underwent a 5-hour procedure consisting of a hysterectomy with unilateral salpingo-oophorectomy, bowel resection, and colostomy.
The woman sued, claiming the surgeon was negligent in injuring her bowel. She further alleged lack of informed consent and improper preparation of the cervix. She argued that in addition to sterility and vaginal scarring, she suffers urinary and bowel incontinence. She maintained that resultant psychological injuries, psychosexual dysfunction, and physiological difficulties have led to problems in her sexual relationship with her husband.
The defense noted that the injuries were known complications of the D&E procedure—a medically necessary intervention. They maintained that sound clinical judgment was exercised at all times.
- The jury returned a defense verdict.
After contracting Parvovirus, a 36-year-old woman suffered fetal demise at 23 weeks’ gestation. Cervical ripening was begun in preparation for a dilation and evacuation (D&E) of the fetal remains. The physician intended to continue this ripening the following morning, but the woman developed a fever and returned to the hospital later that evening.
The physician opted to conduct the D&E that night, but in the course of surgery perforated the woman’s uterus and delivered the bowel vaginally. As a result, the patient underwent a 5-hour procedure consisting of a hysterectomy with unilateral salpingo-oophorectomy, bowel resection, and colostomy.
The woman sued, claiming the surgeon was negligent in injuring her bowel. She further alleged lack of informed consent and improper preparation of the cervix. She argued that in addition to sterility and vaginal scarring, she suffers urinary and bowel incontinence. She maintained that resultant psychological injuries, psychosexual dysfunction, and physiological difficulties have led to problems in her sexual relationship with her husband.
The defense noted that the injuries were known complications of the D&E procedure—a medically necessary intervention. They maintained that sound clinical judgment was exercised at all times.
- The jury returned a defense verdict.
Were chart entries fabricated after woman bled to death?
Following a cesarean delivery and bilateral tubal ligation, a 43-year-old woman died due to hemorrhage.
Her husband, in suing, claimed his wife was left unattended for nearly 2 hours after surgery, during which time she bled to death. He questioned the validity of entries documenting 2 visits in that period, noting that the writing was unusually small and cramped, as if to fit under a later entry.
The defense claimed the chart was accurate and appropriate care administered.
- The case settled for $2.3 million.
Following a cesarean delivery and bilateral tubal ligation, a 43-year-old woman died due to hemorrhage.
Her husband, in suing, claimed his wife was left unattended for nearly 2 hours after surgery, during which time she bled to death. He questioned the validity of entries documenting 2 visits in that period, noting that the writing was unusually small and cramped, as if to fit under a later entry.
The defense claimed the chart was accurate and appropriate care administered.
- The case settled for $2.3 million.
Following a cesarean delivery and bilateral tubal ligation, a 43-year-old woman died due to hemorrhage.
Her husband, in suing, claimed his wife was left unattended for nearly 2 hours after surgery, during which time she bled to death. He questioned the validity of entries documenting 2 visits in that period, noting that the writing was unusually small and cramped, as if to fit under a later entry.
The defense claimed the chart was accurate and appropriate care administered.
- The case settled for $2.3 million.
Was patient not told of leiomyosarcoma tumor?
During a hysterectomy, a physician excised a tumor that a pathology report revealed to be a leiomyosarcoma confined to the uterus. The physician testified that he visualized the field but did not note any additional growths.
Six months later, the patient presented to her internist complaining of abdominal pain. A computed tomography scan demonstrated a large mass; exploratory surgery revealed leiomyosarcoma tumors. Despite chemotherapy and several surgical interventions, the patient died 21 months after the hysterectomy.
In suing, the woman’s family claimed the Ob/Gyn never informed the patient of the cancer’s presence—neither during her hospital stay nor at her 2-week or 6-week postsurgical examination. Further, it was noted that diagnostic studies that are appropriate following cancer resection were not ordered.
The defendant maintained he informed the patient and her husband that an aggressive cancer was removed; however, no notes indicated this conversation took place. The defendant further claimed that a gynecologic oncologist was consulted, but no notation of this was recorded, and the oncologist in question did not recall the alleged conversation.
- The plaintiff was awarded $1.7 million at mediation.
During a hysterectomy, a physician excised a tumor that a pathology report revealed to be a leiomyosarcoma confined to the uterus. The physician testified that he visualized the field but did not note any additional growths.
Six months later, the patient presented to her internist complaining of abdominal pain. A computed tomography scan demonstrated a large mass; exploratory surgery revealed leiomyosarcoma tumors. Despite chemotherapy and several surgical interventions, the patient died 21 months after the hysterectomy.
In suing, the woman’s family claimed the Ob/Gyn never informed the patient of the cancer’s presence—neither during her hospital stay nor at her 2-week or 6-week postsurgical examination. Further, it was noted that diagnostic studies that are appropriate following cancer resection were not ordered.
The defendant maintained he informed the patient and her husband that an aggressive cancer was removed; however, no notes indicated this conversation took place. The defendant further claimed that a gynecologic oncologist was consulted, but no notation of this was recorded, and the oncologist in question did not recall the alleged conversation.
- The plaintiff was awarded $1.7 million at mediation.
During a hysterectomy, a physician excised a tumor that a pathology report revealed to be a leiomyosarcoma confined to the uterus. The physician testified that he visualized the field but did not note any additional growths.
Six months later, the patient presented to her internist complaining of abdominal pain. A computed tomography scan demonstrated a large mass; exploratory surgery revealed leiomyosarcoma tumors. Despite chemotherapy and several surgical interventions, the patient died 21 months after the hysterectomy.
In suing, the woman’s family claimed the Ob/Gyn never informed the patient of the cancer’s presence—neither during her hospital stay nor at her 2-week or 6-week postsurgical examination. Further, it was noted that diagnostic studies that are appropriate following cancer resection were not ordered.
The defendant maintained he informed the patient and her husband that an aggressive cancer was removed; however, no notes indicated this conversation took place. The defendant further claimed that a gynecologic oncologist was consulted, but no notation of this was recorded, and the oncologist in question did not recall the alleged conversation.
- The plaintiff was awarded $1.7 million at mediation.
Uterine rupture follows failed VBAC attempt
A 39-year-old gravida with a previous cesarean delivery (due to twins) opted for a vaginal birth after cesarean (VBAC). She presented for induction of labor due to fetal macrosomia.
When the infant’s head was between -2 and-3 station, the fetal heart rate was noted to be nonreassuring. Medical staff initially believed this was due to normal changes within the second stage of labor, but when labor failed to progress over the next 25 minutes, the defendant physician was called.
The doctor ordered a cesarean delivery 20 minutes after his arrival; however, the procedure did not start until 20 minutes after that. In the interim, evidence of uterine rupture was noted, and the child’s heart rate fell into the 60s. The child suffered severe brain damage and cerebral palsy.
The plaintiffs claimed that had cesarean delivery been initiated at least 15 minutes earlier, neurologic injury might have been avoided.
The defendants denied the delay was unreasonable. Further, they maintained uterine rupture was a known complication of VBAC, and argued that the consent form signed by the mother explained the chance of uterine rupture and the risks associated with it.
- The jury awarded the plaintiffs $14.9 million.
A 39-year-old gravida with a previous cesarean delivery (due to twins) opted for a vaginal birth after cesarean (VBAC). She presented for induction of labor due to fetal macrosomia.
When the infant’s head was between -2 and-3 station, the fetal heart rate was noted to be nonreassuring. Medical staff initially believed this was due to normal changes within the second stage of labor, but when labor failed to progress over the next 25 minutes, the defendant physician was called.
The doctor ordered a cesarean delivery 20 minutes after his arrival; however, the procedure did not start until 20 minutes after that. In the interim, evidence of uterine rupture was noted, and the child’s heart rate fell into the 60s. The child suffered severe brain damage and cerebral palsy.
The plaintiffs claimed that had cesarean delivery been initiated at least 15 minutes earlier, neurologic injury might have been avoided.
The defendants denied the delay was unreasonable. Further, they maintained uterine rupture was a known complication of VBAC, and argued that the consent form signed by the mother explained the chance of uterine rupture and the risks associated with it.
- The jury awarded the plaintiffs $14.9 million.
A 39-year-old gravida with a previous cesarean delivery (due to twins) opted for a vaginal birth after cesarean (VBAC). She presented for induction of labor due to fetal macrosomia.
When the infant’s head was between -2 and-3 station, the fetal heart rate was noted to be nonreassuring. Medical staff initially believed this was due to normal changes within the second stage of labor, but when labor failed to progress over the next 25 minutes, the defendant physician was called.
The doctor ordered a cesarean delivery 20 minutes after his arrival; however, the procedure did not start until 20 minutes after that. In the interim, evidence of uterine rupture was noted, and the child’s heart rate fell into the 60s. The child suffered severe brain damage and cerebral palsy.
The plaintiffs claimed that had cesarean delivery been initiated at least 15 minutes earlier, neurologic injury might have been avoided.
The defendants denied the delay was unreasonable. Further, they maintained uterine rupture was a known complication of VBAC, and argued that the consent form signed by the mother explained the chance of uterine rupture and the risks associated with it.
- The jury awarded the plaintiffs $14.9 million.
When is an infant no longer a newborn?
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.
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.
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.
Document the reason for a nonstress test
To name just a few:
- complaints of decreased fetal movement (655.73)
- fetal size that is small or large for dates (656.53 or 656.63)
- previous intrauterine fetal demise (V23.49)
- abnormal fetal heart rate (659.73)
- maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).
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.
To name just a few:
- complaints of decreased fetal movement (655.73)
- fetal size that is small or large for dates (656.53 or 656.63)
- previous intrauterine fetal demise (V23.49)
- abnormal fetal heart rate (659.73)
- maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).
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.
To name just a few:
- complaints of decreased fetal movement (655.73)
- fetal size that is small or large for dates (656.53 or 656.63)
- previous intrauterine fetal demise (V23.49)
- abnormal fetal heart rate (659.73)
- maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).
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.
Postcoital exam denied: Now what?
Another issue may be that the patient does not have coverage for infertility services, including testing.
If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).
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.
Another issue may be that the patient does not have coverage for infertility services, including testing.
If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).
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.
Another issue may be that the patient does not have coverage for infertility services, including testing.
If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).
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.
Could timely appendectomy have prevented preterm birth?
Symptoms of nausea, vomiting, and right lower quadrant abdominal pain prompted a woman at 28 weeks’ gestation to present to a medical center. Her white blood cell count (WBC) was 22,700. After preterm labor was ruled out, the woman was given analgesics and sent home.
The following day the woman returned to the hospital, noting the same symptoms plus diarrhea. Her WBC at this time was 23,500. When no contractions were detected, the woman was given additional pain medication and again discharged home.
Two days after her last visit, she once again presented to the hospital, this time noting sharp pains. An appendectomy was then scheduled with a general surgeon. By this time, however, labor had begun and could not be stopped. The woman delivered the child, who suffers from cerebral palsy and spastic quadriparesis.
The mother claimed that the defendant either misread or failed to assess her WBC and clinical presentation. She argued that a gener-al surgeon should have been consulted during 1 of her initial 2 visits. Had an appendectomy been performed at that time, she claimed, she had a 90% chance of carrying the child to term.
The defendant maintained the standard of care was met at all times.
- The case settled for $2 million.
Symptoms of nausea, vomiting, and right lower quadrant abdominal pain prompted a woman at 28 weeks’ gestation to present to a medical center. Her white blood cell count (WBC) was 22,700. After preterm labor was ruled out, the woman was given analgesics and sent home.
The following day the woman returned to the hospital, noting the same symptoms plus diarrhea. Her WBC at this time was 23,500. When no contractions were detected, the woman was given additional pain medication and again discharged home.
Two days after her last visit, she once again presented to the hospital, this time noting sharp pains. An appendectomy was then scheduled with a general surgeon. By this time, however, labor had begun and could not be stopped. The woman delivered the child, who suffers from cerebral palsy and spastic quadriparesis.
The mother claimed that the defendant either misread or failed to assess her WBC and clinical presentation. She argued that a gener-al surgeon should have been consulted during 1 of her initial 2 visits. Had an appendectomy been performed at that time, she claimed, she had a 90% chance of carrying the child to term.
The defendant maintained the standard of care was met at all times.
- The case settled for $2 million.
Symptoms of nausea, vomiting, and right lower quadrant abdominal pain prompted a woman at 28 weeks’ gestation to present to a medical center. Her white blood cell count (WBC) was 22,700. After preterm labor was ruled out, the woman was given analgesics and sent home.
The following day the woman returned to the hospital, noting the same symptoms plus diarrhea. Her WBC at this time was 23,500. When no contractions were detected, the woman was given additional pain medication and again discharged home.
Two days after her last visit, she once again presented to the hospital, this time noting sharp pains. An appendectomy was then scheduled with a general surgeon. By this time, however, labor had begun and could not be stopped. The woman delivered the child, who suffers from cerebral palsy and spastic quadriparesis.
The mother claimed that the defendant either misread or failed to assess her WBC and clinical presentation. She argued that a gener-al surgeon should have been consulted during 1 of her initial 2 visits. Had an appendectomy been performed at that time, she claimed, she had a 90% chance of carrying the child to term.
The defendant maintained the standard of care was met at all times.
- The case settled for $2 million.
Myomectomy performed: Was hysterectomy indicated?
Narcotic analgesics failed to resolve the symptoms of a 32-year-old woman with menorrhagia, cramping, and pain. Her family physician therefore ordered a pelvic ultrasound. The study revealed multiple myomas, and the patient was referred to an Ob/Gyn.
In discussions with the Ob/Gyn, the patient expressed her desire for a hysterectomy to resolve the problem. During surgery, how-ever, the physician discovered that no fibroids existed within the uterus; rather, a large myoma on a stalk was attached to the patient’s uterus. The doctor opted to remove the fibroid at the stalk, leaving the uterus intact.
Following surgery, the patient’s symptoms continued. She sought treatment from several other physicians, and approximately 1 year after the initial procedure had a hysterec-tomy. She claims she is now symptom-free.
In suing, the plaintiff argued that her understanding of the initial procedure was that a hysterectomy would be performed, to ensure permanent resolution of her symptoms. She alleged that in opting for a myomectomy, the defendant conducted a surgery for which she had not given consent. She sought damages for pain and suffering, as well as lost wages.
The defendant claimed it was not necessary to inform the patient of changes in the planned surgery based on unsuspected pathology, and that the woman was told that additional procedures might be required.
- The jury returned a defense verdict.
Narcotic analgesics failed to resolve the symptoms of a 32-year-old woman with menorrhagia, cramping, and pain. Her family physician therefore ordered a pelvic ultrasound. The study revealed multiple myomas, and the patient was referred to an Ob/Gyn.
In discussions with the Ob/Gyn, the patient expressed her desire for a hysterectomy to resolve the problem. During surgery, how-ever, the physician discovered that no fibroids existed within the uterus; rather, a large myoma on a stalk was attached to the patient’s uterus. The doctor opted to remove the fibroid at the stalk, leaving the uterus intact.
Following surgery, the patient’s symptoms continued. She sought treatment from several other physicians, and approximately 1 year after the initial procedure had a hysterec-tomy. She claims she is now symptom-free.
In suing, the plaintiff argued that her understanding of the initial procedure was that a hysterectomy would be performed, to ensure permanent resolution of her symptoms. She alleged that in opting for a myomectomy, the defendant conducted a surgery for which she had not given consent. She sought damages for pain and suffering, as well as lost wages.
The defendant claimed it was not necessary to inform the patient of changes in the planned surgery based on unsuspected pathology, and that the woman was told that additional procedures might be required.
- The jury returned a defense verdict.
Narcotic analgesics failed to resolve the symptoms of a 32-year-old woman with menorrhagia, cramping, and pain. Her family physician therefore ordered a pelvic ultrasound. The study revealed multiple myomas, and the patient was referred to an Ob/Gyn.
In discussions with the Ob/Gyn, the patient expressed her desire for a hysterectomy to resolve the problem. During surgery, how-ever, the physician discovered that no fibroids existed within the uterus; rather, a large myoma on a stalk was attached to the patient’s uterus. The doctor opted to remove the fibroid at the stalk, leaving the uterus intact.
Following surgery, the patient’s symptoms continued. She sought treatment from several other physicians, and approximately 1 year after the initial procedure had a hysterec-tomy. She claims she is now symptom-free.
In suing, the plaintiff argued that her understanding of the initial procedure was that a hysterectomy would be performed, to ensure permanent resolution of her symptoms. She alleged that in opting for a myomectomy, the defendant conducted a surgery for which she had not given consent. She sought damages for pain and suffering, as well as lost wages.
The defendant claimed it was not necessary to inform the patient of changes in the planned surgery based on unsuspected pathology, and that the woman was told that additional procedures might be required.
- The jury returned a defense verdict.