Managing Your Practice

Palestine County (Tex) 349th Judicial District Court

During a patient’s labor, a nurse anesthetist administered an epidural spinal block for pain. An Ob/Gyn examined the patient soon after, then left. Shortly after the doctor departed, fetal distress occurred, but the nurses allegedly failed to notice the change in fetal status.

When the baby was delivered approximately 2 hours later, she was limp, apneic, and had a heart rate of 40. Her Apgar scores were 1 at 1 minute, 3 at 5 minutes, and 4 at 10 minutes. The cord pH was abnormal at 6.71. The child now suffers from severe brain damage due to hypoxia.

The mother sued, claiming the doctor and nurses waited too long to deliver the baby and failed to recognize the fetal distress. She further argued that a fetal scalp electrode should have been used but was not.

Hospital staff contended that the baby’s brain injury stemmed from a preexisting maternal condition.

• The case settled for $10,025,000.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Palestine County (Tex) 349th Judicial District Court

During a patient’s labor, a nurse anesthetist administered an epidural spinal block for pain. An Ob/Gyn examined the patient soon after, then left. Shortly after the doctor departed, fetal distress occurred, but the nurses allegedly failed to notice the change in fetal status.

When the baby was delivered approximately 2 hours later, she was limp, apneic, and had a heart rate of 40. Her Apgar scores were 1 at 1 minute, 3 at 5 minutes, and 4 at 10 minutes. The cord pH was abnormal at 6.71. The child now suffers from severe brain damage due to hypoxia.

The mother sued, claiming the doctor and nurses waited too long to deliver the baby and failed to recognize the fetal distress. She further argued that a fetal scalp electrode should have been used but was not.

Hospital staff contended that the baby’s brain injury stemmed from a preexisting maternal condition.

• The case settled for $10,025,000.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Palestine County (Tex) 349th Judicial District Court

During a patient’s labor, a nurse anesthetist administered an epidural spinal block for pain. An Ob/Gyn examined the patient soon after, then left. Shortly after the doctor departed, fetal distress occurred, but the nurses allegedly failed to notice the change in fetal status.

When the baby was delivered approximately 2 hours later, she was limp, apneic, and had a heart rate of 40. Her Apgar scores were 1 at 1 minute, 3 at 5 minutes, and 4 at 10 minutes. The cord pH was abnormal at 6.71. The child now suffers from severe brain damage due to hypoxia.

The mother sued, claiming the doctor and nurses waited too long to deliver the baby and failed to recognize the fetal distress. She further argued that a fetal scalp electrode should have been used but was not.

Hospital staff contended that the baby’s brain injury stemmed from a preexisting maternal condition.

• The case settled for $10,025,000.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Cook County (Ill) Circuit Court

A newborn required intubation following delivery. However, a nurse anesthetist placed the breathing tube into the right mainstem bronchus instead of the trachea. By the time the problem was discovered and corrected 2 hours later, the baby had suffered pneumothorax of the right lung and a collapse of the left lung, resulting in irreversible brain damage.

In suing, the child—now 17—argued that the doctor was slow to respond to fetal distress on the monitor strips.

The doctor argued that the negligence did not cause the child’s brain injury.

• The case settled for $18 million from the hospital and $400,000 from the physician.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Cook County (Ill) Circuit Court

A newborn required intubation following delivery. However, a nurse anesthetist placed the breathing tube into the right mainstem bronchus instead of the trachea. By the time the problem was discovered and corrected 2 hours later, the baby had suffered pneumothorax of the right lung and a collapse of the left lung, resulting in irreversible brain damage.

In suing, the child—now 17—argued that the doctor was slow to respond to fetal distress on the monitor strips.

The doctor argued that the negligence did not cause the child’s brain injury.

• The case settled for $18 million from the hospital and $400,000 from the physician.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Cook County (Ill) Circuit Court

A newborn required intubation following delivery. However, a nurse anesthetist placed the breathing tube into the right mainstem bronchus instead of the trachea. By the time the problem was discovered and corrected 2 hours later, the baby had suffered pneumothorax of the right lung and a collapse of the left lung, resulting in irreversible brain damage.

In suing, the child—now 17—argued that the doctor was slow to respond to fetal distress on the monitor strips.

The doctor argued that the negligence did not cause the child’s brain injury.

• The case settled for $18 million from the hospital and $400,000 from the physician.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Harris County (Tex) District Court

During the delivery of her fifth child, a woman suffered an amniotic fluid embolism and died. Her son was delivered successfully.

The patient’s husband sued, alleging that the doctors were negligent in failing to perform a timely cesarean section. He claimed that his wife suffered a uterine tear as a result of the prolonged induced labor.

The doctors asserted that amniotic fluid embolism is unpredictable and untreatable.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Harris County (Tex) District Court

During the delivery of her fifth child, a woman suffered an amniotic fluid embolism and died. Her son was delivered successfully.

The patient’s husband sued, alleging that the doctors were negligent in failing to perform a timely cesarean section. He claimed that his wife suffered a uterine tear as a result of the prolonged induced labor.

The doctors asserted that amniotic fluid embolism is unpredictable and untreatable.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Harris County (Tex) District Court

During the delivery of her fifth child, a woman suffered an amniotic fluid embolism and died. Her son was delivered successfully.

The patient’s husband sued, alleging that the doctors were negligent in failing to perform a timely cesarean section. He claimed that his wife suffered a uterine tear as a result of the prolonged induced labor.

The doctors asserted that amniotic fluid embolism is unpredictable and untreatable.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Ventura County (Calif) Superior Court

A 38-year-old woman complained of pelvic pain on her left side. Her physician performed an ultrasound and discovered multiple uterine fibroids. He recommended she undergo surgery once the pain became unbearable.

Three months later, the woman reported cramping and severe pain during intercourse. The doctor prescribed a painkiller and scheduled a surgery in 2 months. Since the consulting doctor no longer performed surgery, the woman was referred to his partner.

During her preoperative visit, the patient was given an informed consent form for hysterectomy in which ovary removal was mentioned. At trial the woman claimed to have told the doctor she did not want her ovaries removed. She said the physician called the form a formality and reassured her that he would not remove her ovaries.

During the operation, the doctor discovered severe endometriosis over both ovaries, obliterating the pelvic cul-de-sac. The woman’s condition was further complicated by severe adhesions. The doctor then performed a bilateral salpingo-oophorectomy and prescribed a course of hormone replacement therapy.

In suing, the woman claimed the doctor lacked informed consent to remove her ovaries. She also reiterated her strong desire to preserve her ovaries despite the pathology.

The doctor contended that he had acted within the standard of care and said the woman’s signature on the consent form approved the possibility of ovary removal. He also argued that the severe condition of her ovaries necessitated removal.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Ventura County (Calif) Superior Court

A 38-year-old woman complained of pelvic pain on her left side. Her physician performed an ultrasound and discovered multiple uterine fibroids. He recommended she undergo surgery once the pain became unbearable.

Three months later, the woman reported cramping and severe pain during intercourse. The doctor prescribed a painkiller and scheduled a surgery in 2 months. Since the consulting doctor no longer performed surgery, the woman was referred to his partner.

During her preoperative visit, the patient was given an informed consent form for hysterectomy in which ovary removal was mentioned. At trial the woman claimed to have told the doctor she did not want her ovaries removed. She said the physician called the form a formality and reassured her that he would not remove her ovaries.

During the operation, the doctor discovered severe endometriosis over both ovaries, obliterating the pelvic cul-de-sac. The woman’s condition was further complicated by severe adhesions. The doctor then performed a bilateral salpingo-oophorectomy and prescribed a course of hormone replacement therapy.

In suing, the woman claimed the doctor lacked informed consent to remove her ovaries. She also reiterated her strong desire to preserve her ovaries despite the pathology.

The doctor contended that he had acted within the standard of care and said the woman’s signature on the consent form approved the possibility of ovary removal. He also argued that the severe condition of her ovaries necessitated removal.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Ventura County (Calif) Superior Court

A 38-year-old woman complained of pelvic pain on her left side. Her physician performed an ultrasound and discovered multiple uterine fibroids. He recommended she undergo surgery once the pain became unbearable.

Three months later, the woman reported cramping and severe pain during intercourse. The doctor prescribed a painkiller and scheduled a surgery in 2 months. Since the consulting doctor no longer performed surgery, the woman was referred to his partner.

During her preoperative visit, the patient was given an informed consent form for hysterectomy in which ovary removal was mentioned. At trial the woman claimed to have told the doctor she did not want her ovaries removed. She said the physician called the form a formality and reassured her that he would not remove her ovaries.

During the operation, the doctor discovered severe endometriosis over both ovaries, obliterating the pelvic cul-de-sac. The woman’s condition was further complicated by severe adhesions. The doctor then performed a bilateral salpingo-oophorectomy and prescribed a course of hormone replacement therapy.

In suing, the woman claimed the doctor lacked informed consent to remove her ovaries. She also reiterated her strong desire to preserve her ovaries despite the pathology.

The doctor contended that he had acted within the standard of care and said the woman’s signature on the consent form approved the possibility of ovary removal. He also argued that the severe condition of her ovaries necessitated removal.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A 49-year-old woman delivered her second child vaginally after a previous cesarean section. During delivery, she required an episiotomy and experienced a fourth-degree tear.

Six days after her discharge, the patient’s husband called the doctor to report that his wife was suffering from severe constipation. The doctor advised him to give her an enema. The first enema had no effect, so a second one was administered. Later, the woman experienced a bloody bowel movement. The doctor diagnosed her with cloaca, a merger of the vaginal and rectal openings. She was referred to a colorectal surgeon to repair the condition.

At the time of trial, the patient said she continued to suffer from incontinence and had not engaged in sexual intercourse due to pain. She claimed that the doctor failed to advise her of the risks of an episiotomy or instruct her on how to care for the site. In addition, she contended that she was discharged without having a bowel movement. Further, she argued that recommending an enema without conducting an examination violated the standard of care. She said the enema’s hard nozzle may have caused trauma to the tissue and damaged the episiotomy.

The doctor argued that the bowel movement caused the problem, not the enema, and observed that an enema is the safest and most effective way to treat constipation.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A 49-year-old woman delivered her second child vaginally after a previous cesarean section. During delivery, she required an episiotomy and experienced a fourth-degree tear.

Six days after her discharge, the patient’s husband called the doctor to report that his wife was suffering from severe constipation. The doctor advised him to give her an enema. The first enema had no effect, so a second one was administered. Later, the woman experienced a bloody bowel movement. The doctor diagnosed her with cloaca, a merger of the vaginal and rectal openings. She was referred to a colorectal surgeon to repair the condition.

At the time of trial, the patient said she continued to suffer from incontinence and had not engaged in sexual intercourse due to pain. She claimed that the doctor failed to advise her of the risks of an episiotomy or instruct her on how to care for the site. In addition, she contended that she was discharged without having a bowel movement. Further, she argued that recommending an enema without conducting an examination violated the standard of care. She said the enema’s hard nozzle may have caused trauma to the tissue and damaged the episiotomy.

The doctor argued that the bowel movement caused the problem, not the enema, and observed that an enema is the safest and most effective way to treat constipation.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Plymouth County (Mass) Superior Court

A 49-year-old woman delivered her second child vaginally after a previous cesarean section. During delivery, she required an episiotomy and experienced a fourth-degree tear.

Six days after her discharge, the patient’s husband called the doctor to report that his wife was suffering from severe constipation. The doctor advised him to give her an enema. The first enema had no effect, so a second one was administered. Later, the woman experienced a bloody bowel movement. The doctor diagnosed her with cloaca, a merger of the vaginal and rectal openings. She was referred to a colorectal surgeon to repair the condition.

At the time of trial, the patient said she continued to suffer from incontinence and had not engaged in sexual intercourse due to pain. She claimed that the doctor failed to advise her of the risks of an episiotomy or instruct her on how to care for the site. In addition, she contended that she was discharged without having a bowel movement. Further, she argued that recommending an enema without conducting an examination violated the standard of care. She said the enema’s hard nozzle may have caused trauma to the tissue and damaged the episiotomy.

The doctor argued that the bowel movement caused the problem, not the enema, and observed that an enema is the safest and most effective way to treat constipation.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Brockton (Mass) Superior Court

When a 62-year-old woman complained of a slight swelling in her armpit, her physician allegedly told her that thyroid blood tests and blood pressure checks he had performed at a previous visit were sufficient to rule out cancer. He also noted that her annual mammograms were negative.

Eighteen months later, the woman alleged, she presented with a walnut-sized lump in her armpit, but the doctor did not detect a mass. In another 6 months, the physician detected a mass and diagnosed terminal stage IV breast cancer.

In court, the woman claimed the physician gave her a false sense of security when he said blood work would be enough to detect breast cancer. Further, she contended that his follow-up procedures and delayed diagnosis did not fall within the standard of care.

The doctor maintained the woman did not complain of armpit swelling or pain until just before he diagnosed her with breast cancer.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Brockton (Mass) Superior Court

When a 62-year-old woman complained of a slight swelling in her armpit, her physician allegedly told her that thyroid blood tests and blood pressure checks he had performed at a previous visit were sufficient to rule out cancer. He also noted that her annual mammograms were negative.

Eighteen months later, the woman alleged, she presented with a walnut-sized lump in her armpit, but the doctor did not detect a mass. In another 6 months, the physician detected a mass and diagnosed terminal stage IV breast cancer.

In court, the woman claimed the physician gave her a false sense of security when he said blood work would be enough to detect breast cancer. Further, she contended that his follow-up procedures and delayed diagnosis did not fall within the standard of care.

The doctor maintained the woman did not complain of armpit swelling or pain until just before he diagnosed her with breast cancer.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Brockton (Mass) Superior Court

When a 62-year-old woman complained of a slight swelling in her armpit, her physician allegedly told her that thyroid blood tests and blood pressure checks he had performed at a previous visit were sufficient to rule out cancer. He also noted that her annual mammograms were negative.

Eighteen months later, the woman alleged, she presented with a walnut-sized lump in her armpit, but the doctor did not detect a mass. In another 6 months, the physician detected a mass and diagnosed terminal stage IV breast cancer.

In court, the woman claimed the physician gave her a false sense of security when he said blood work would be enough to detect breast cancer. Further, she contended that his follow-up procedures and delayed diagnosis did not fall within the standard of care.

The doctor maintained the woman did not complain of armpit swelling or pain until just before he diagnosed her with breast cancer.

• The jury returned a defense verdict.
  

The cases presented here were compiled by Lewis L. Laska, editor of Medical Malpractice Verdicts, Settlements & Experts. While there are instances when the available information is incomplete, these cases represent the types of clinical situations that typically result in litigation.

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.