Managing Your Practice

Dallas County (Tex) District Court—On September 21, a gravida, suffering from severe back pain at term, presented to the emergency room. An ultrasound revealed a mass in front of the patient’s uterus interpreted as a hematoma due to blood loss from a leak in the common iliac artery. She underwent an iliac graft and cesarean delivery of a stillborn infant. Seven days later, the woman died from massive organ failure.

The patient’s family sued, arguing that the primary obstetricians caused 2 deaths as a result of their failure to diagnose the common iliac artery leak. Denying negligence, the defendants claimed that the woman had Ehlers-Danlos syndrome, a rare genetic disorder, which led to the deaths.

The jury awarded the plaintiffs $440,514.

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.

Dallas County (Tex) District Court—On September 21, a gravida, suffering from severe back pain at term, presented to the emergency room. An ultrasound revealed a mass in front of the patient’s uterus interpreted as a hematoma due to blood loss from a leak in the common iliac artery. She underwent an iliac graft and cesarean delivery of a stillborn infant. Seven days later, the woman died from massive organ failure.

The patient’s family sued, arguing that the primary obstetricians caused 2 deaths as a result of their failure to diagnose the common iliac artery leak. Denying negligence, the defendants claimed that the woman had Ehlers-Danlos syndrome, a rare genetic disorder, which led to the deaths.

The jury awarded the plaintiffs $440,514.

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.

Dallas County (Tex) District Court—On September 21, a gravida, suffering from severe back pain at term, presented to the emergency room. An ultrasound revealed a mass in front of the patient’s uterus interpreted as a hematoma due to blood loss from a leak in the common iliac artery. She underwent an iliac graft and cesarean delivery of a stillborn infant. Seven days later, the woman died from massive organ failure.

The patient’s family sued, arguing that the primary obstetricians caused 2 deaths as a result of their failure to diagnose the common iliac artery leak. Denying negligence, the defendants claimed that the woman had Ehlers-Danlos syndrome, a rare genetic disorder, which led to the deaths.

The jury awarded the plaintiffs $440,514.

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.

Montgomery County (Md) Circuit Court—A 28-year-old-woman presented to a clinic to undergo an abortion, which was performed successfully under general anesthesia. In the recovery room, the nurses had difficulty waking the patient, so the anesthesiologist prescribed medication to hasten her recovery. The nurses, however, discovered the patient was suffering a hypoxic event due to an obstructed airway. They attempted to oxygenate the patient using a pediatric-sized resuscitation bag but did not try to intubate her. The patient died 12 hours later due to irreversible brain damage.

In suing, the patient’s family claimed that the clinic failed to properly monitor the woman because it did not have a pulse oximeter machine nor enough Dyna-Map machines to monitor her blood pressure. Further, there were no adult resuscitation bags, and the nurses failed to use an EKG machine when trying to resuscitate her. In defense, the anesthesiologist said the nurses did not alert her to any problems, but the clinic nurses said the physician was aware of the patient’s problem but failed to check her condition.

In a settlement agreement, the plaintiffs received $1.3 million.

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.

Montgomery County (Md) Circuit Court—A 28-year-old-woman presented to a clinic to undergo an abortion, which was performed successfully under general anesthesia. In the recovery room, the nurses had difficulty waking the patient, so the anesthesiologist prescribed medication to hasten her recovery. The nurses, however, discovered the patient was suffering a hypoxic event due to an obstructed airway. They attempted to oxygenate the patient using a pediatric-sized resuscitation bag but did not try to intubate her. The patient died 12 hours later due to irreversible brain damage.

In suing, the patient’s family claimed that the clinic failed to properly monitor the woman because it did not have a pulse oximeter machine nor enough Dyna-Map machines to monitor her blood pressure. Further, there were no adult resuscitation bags, and the nurses failed to use an EKG machine when trying to resuscitate her. In defense, the anesthesiologist said the nurses did not alert her to any problems, but the clinic nurses said the physician was aware of the patient’s problem but failed to check her condition.

In a settlement agreement, the plaintiffs received $1.3 million.

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.

Montgomery County (Md) Circuit Court—A 28-year-old-woman presented to a clinic to undergo an abortion, which was performed successfully under general anesthesia. In the recovery room, the nurses had difficulty waking the patient, so the anesthesiologist prescribed medication to hasten her recovery. The nurses, however, discovered the patient was suffering a hypoxic event due to an obstructed airway. They attempted to oxygenate the patient using a pediatric-sized resuscitation bag but did not try to intubate her. The patient died 12 hours later due to irreversible brain damage.

In suing, the patient’s family claimed that the clinic failed to properly monitor the woman because it did not have a pulse oximeter machine nor enough Dyna-Map machines to monitor her blood pressure. Further, there were no adult resuscitation bags, and the nurses failed to use an EKG machine when trying to resuscitate her. In defense, the anesthesiologist said the nurses did not alert her to any problems, but the clinic nurses said the physician was aware of the patient’s problem but failed to check her condition.

In a settlement agreement, the plaintiffs received $1.3 million.

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—An Ob/Gyn vaginally delivered an infant weighing 10 lb, 11 oz. During the delivery, shoulder dystocia occurred. The child suffered Erb’s palsy and Klumpke’s paralysis in his right arm. The mother sustained a fourth-degree laceration and subsequently developed a rectovaginal fistula, which required repair.

The woman sued, claiming the Ob/Gyn should have performed a cesarean delivery because of her history of fibroids and obesity, the fetus’ accelerated growth rate, and arrest of descent during labor, which required the use of oxytocin. She argued that the physician attempted vacuum extraction without a clinical indication and used improper delivery maneuvers and fundal pressure.

According to the defense, the pregnancy was normal. The fibroids did not pose a problem, and the ultrasounds showed normal fetal growth. In addition to contending that the dystocia was severe and unpredictable, the defendant testified that all delivery maneuvers were correct, fundal pressure wasn’t used, and the rectovaginal fistula was a known complication of the repair of a fourth-degree laceration.

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.

Cook County (Ill) Circuit Court—An Ob/Gyn vaginally delivered an infant weighing 10 lb, 11 oz. During the delivery, shoulder dystocia occurred. The child suffered Erb’s palsy and Klumpke’s paralysis in his right arm. The mother sustained a fourth-degree laceration and subsequently developed a rectovaginal fistula, which required repair.

The woman sued, claiming the Ob/Gyn should have performed a cesarean delivery because of her history of fibroids and obesity, the fetus’ accelerated growth rate, and arrest of descent during labor, which required the use of oxytocin. She argued that the physician attempted vacuum extraction without a clinical indication and used improper delivery maneuvers and fundal pressure.

According to the defense, the pregnancy was normal. The fibroids did not pose a problem, and the ultrasounds showed normal fetal growth. In addition to contending that the dystocia was severe and unpredictable, the defendant testified that all delivery maneuvers were correct, fundal pressure wasn’t used, and the rectovaginal fistula was a known complication of the repair of a fourth-degree laceration.

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.

Cook County (Ill) Circuit Court—An Ob/Gyn vaginally delivered an infant weighing 10 lb, 11 oz. During the delivery, shoulder dystocia occurred. The child suffered Erb’s palsy and Klumpke’s paralysis in his right arm. The mother sustained a fourth-degree laceration and subsequently developed a rectovaginal fistula, which required repair.

The woman sued, claiming the Ob/Gyn should have performed a cesarean delivery because of her history of fibroids and obesity, the fetus’ accelerated growth rate, and arrest of descent during labor, which required the use of oxytocin. She argued that the physician attempted vacuum extraction without a clinical indication and used improper delivery maneuvers and fundal pressure.

According to the defense, the pregnancy was normal. The fibroids did not pose a problem, and the ultrasounds showed normal fetal growth. In addition to contending that the dystocia was severe and unpredictable, the defendant testified that all delivery maneuvers were correct, fundal pressure wasn’t used, and the rectovaginal fistula was a known complication of the repair of a fourth-degree laceration.

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.

Kings County (Ny) Supreme Court—On May 3, a gravida at 23 weeks’ gestation presented to a hospital clinic for a routine prenatal visit, at which time the obstetrician did not perform an internal exam. She presented again 8 days later, when it was determined that her cervix had dilated 2 cm and her membranes were bulging. Following admission, she was confined to bed and scheduled for the placement of a cerclage for an incompetent cervix. However, the procedure was delayed for 5 days, and on May 16, the woman vaginally delivered an infant, who subsequently suffers from spastic quadriplegia, blindness, and delayed mental development.

In suing, the mother claimed that the infant’s brain damage was the result of the obstetrician’s failure to place a cervical cerclage, which would have prevented preterm labor and delivery. She also asserted that there was no electronic fetal monitoring during labor; had there been, fetal distress would have been detected, allowing for a timely cesarean delivery to prevent hypoxia. Furthermore, the patient contended that an internal exam should have been performed during her visit on May 3, that a pediatrician should have been present during delivery, and that the physician didn’t intubate the infant in a timely manner. However, she did concede that most of the baby’s problems were due to his prematurity.

The defendant denied that the gravida presented to the hospital clinic on May 3. Citing the woman’s subsequent delivery of another healthy child, the physician argued that she didn’t have an incompetent cervix. Rather, the chorioamnionitis caused the preterm labor. He testified that a pediatrician was present at delivery.

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.

Kings County (Ny) Supreme Court—On May 3, a gravida at 23 weeks’ gestation presented to a hospital clinic for a routine prenatal visit, at which time the obstetrician did not perform an internal exam. She presented again 8 days later, when it was determined that her cervix had dilated 2 cm and her membranes were bulging. Following admission, she was confined to bed and scheduled for the placement of a cerclage for an incompetent cervix. However, the procedure was delayed for 5 days, and on May 16, the woman vaginally delivered an infant, who subsequently suffers from spastic quadriplegia, blindness, and delayed mental development.

In suing, the mother claimed that the infant’s brain damage was the result of the obstetrician’s failure to place a cervical cerclage, which would have prevented preterm labor and delivery. She also asserted that there was no electronic fetal monitoring during labor; had there been, fetal distress would have been detected, allowing for a timely cesarean delivery to prevent hypoxia. Furthermore, the patient contended that an internal exam should have been performed during her visit on May 3, that a pediatrician should have been present during delivery, and that the physician didn’t intubate the infant in a timely manner. However, she did concede that most of the baby’s problems were due to his prematurity.

The defendant denied that the gravida presented to the hospital clinic on May 3. Citing the woman’s subsequent delivery of another healthy child, the physician argued that she didn’t have an incompetent cervix. Rather, the chorioamnionitis caused the preterm labor. He testified that a pediatrician was present at delivery.

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.

Kings County (Ny) Supreme Court—On May 3, a gravida at 23 weeks’ gestation presented to a hospital clinic for a routine prenatal visit, at which time the obstetrician did not perform an internal exam. She presented again 8 days later, when it was determined that her cervix had dilated 2 cm and her membranes were bulging. Following admission, she was confined to bed and scheduled for the placement of a cerclage for an incompetent cervix. However, the procedure was delayed for 5 days, and on May 16, the woman vaginally delivered an infant, who subsequently suffers from spastic quadriplegia, blindness, and delayed mental development.

In suing, the mother claimed that the infant’s brain damage was the result of the obstetrician’s failure to place a cervical cerclage, which would have prevented preterm labor and delivery. She also asserted that there was no electronic fetal monitoring during labor; had there been, fetal distress would have been detected, allowing for a timely cesarean delivery to prevent hypoxia. Furthermore, the patient contended that an internal exam should have been performed during her visit on May 3, that a pediatrician should have been present during delivery, and that the physician didn’t intubate the infant in a timely manner. However, she did concede that most of the baby’s problems were due to his prematurity.

The defendant denied that the gravida presented to the hospital clinic on May 3. Citing the woman’s subsequent delivery of another healthy child, the physician argued that she didn’t have an incompetent cervix. Rather, the chorioamnionitis caused the preterm labor. He testified that a pediatrician was present at delivery.

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.

Morris County (Nj) Superior Court—On May 11, a gravida at 24 weeks’ gestation presented to her obstetrician, who diagnosed her with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Five days later, she underwent an emergency cesarean delivery of a severely disabled infant.

The mother sued, claiming the obstetrician should have recognized the seriousness of the problem when the lab results from May 11 showed elevated enzyme levels and a low platelet count. Additionally, she alleged that once HELLP syndrome was diagnosed, she and the father should have been given the option of immediately terminating the pregnancy because there was a 90% chance the infant would be born with significant disabilities. The defendant asserted he could not have detected her condition at such an early stage.

A $950,000 settlement was reached.

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.

Morris County (Nj) Superior Court—On May 11, a gravida at 24 weeks’ gestation presented to her obstetrician, who diagnosed her with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Five days later, she underwent an emergency cesarean delivery of a severely disabled infant.

The mother sued, claiming the obstetrician should have recognized the seriousness of the problem when the lab results from May 11 showed elevated enzyme levels and a low platelet count. Additionally, she alleged that once HELLP syndrome was diagnosed, she and the father should have been given the option of immediately terminating the pregnancy because there was a 90% chance the infant would be born with significant disabilities. The defendant asserted he could not have detected her condition at such an early stage.

A $950,000 settlement was reached.

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.

Morris County (Nj) Superior Court—On May 11, a gravida at 24 weeks’ gestation presented to her obstetrician, who diagnosed her with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Five days later, she underwent an emergency cesarean delivery of a severely disabled infant.

The mother sued, claiming the obstetrician should have recognized the seriousness of the problem when the lab results from May 11 showed elevated enzyme levels and a low platelet count. Additionally, she alleged that once HELLP syndrome was diagnosed, she and the father should have been given the option of immediately terminating the pregnancy because there was a 90% chance the infant would be born with significant disabilities. The defendant asserted he could not have detected her condition at such an early stage.

A $950,000 settlement was reached.

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.

Baltimore County (Md) Circuit Court—During labor, an Ob/Gyn encountered arrest of fetal descent. He eventually delivered the fetus using forceps and encountered a shoulder dystocia. The infant suffered a fractured collarbone and a brachial plexus injury, resulting in Erb’s palsy.

The mother asserted there were indications of cephalopelvic disproportion (CPD), a condition that warrants a cesarean delivery. The physician contended there were no signs of CPD. The patient’s records, however, contained notes from the defendant indicating there were “clinical indications of CPD with a small mother and a large baby.” He also said shoulder dystocia is a regularly occurring complication of childbirth.

The jury awarded the plaintiff $425,000.

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.

Baltimore County (Md) Circuit Court—During labor, an Ob/Gyn encountered arrest of fetal descent. He eventually delivered the fetus using forceps and encountered a shoulder dystocia. The infant suffered a fractured collarbone and a brachial plexus injury, resulting in Erb’s palsy.

The mother asserted there were indications of cephalopelvic disproportion (CPD), a condition that warrants a cesarean delivery. The physician contended there were no signs of CPD. The patient’s records, however, contained notes from the defendant indicating there were “clinical indications of CPD with a small mother and a large baby.” He also said shoulder dystocia is a regularly occurring complication of childbirth.

The jury awarded the plaintiff $425,000.

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.

Baltimore County (Md) Circuit Court—During labor, an Ob/Gyn encountered arrest of fetal descent. He eventually delivered the fetus using forceps and encountered a shoulder dystocia. The infant suffered a fractured collarbone and a brachial plexus injury, resulting in Erb’s palsy.

The mother asserted there were indications of cephalopelvic disproportion (CPD), a condition that warrants a cesarean delivery. The physician contended there were no signs of CPD. The patient’s records, however, contained notes from the defendant indicating there were “clinical indications of CPD with a small mother and a large baby.” He also said shoulder dystocia is a regularly occurring complication of childbirth.

The jury awarded the plaintiff $425,000.

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.

Tarrant County (Tex) District Court—When his patient’s menorrhagia failed to improve with conservative treatment, a gynecologist performed a hysterectomy. Postoperatively, the woman suffered continued blood loss and died 11 weeks later.

The patient’s family sued, claiming that the intractable bleeding led the patient to develop disseminated intravascular coagulation (DIC), which caused the onset of adult respiratory distress syndrome (ARDS). The defendant contended that the woman never developed DIC. He claimed that the patient’s pre-existing bacterial endocarditis caused aspiration, which resulted in ARDS.

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.

Tarrant County (Tex) District Court—When his patient’s menorrhagia failed to improve with conservative treatment, a gynecologist performed a hysterectomy. Postoperatively, the woman suffered continued blood loss and died 11 weeks later.

The patient’s family sued, claiming that the intractable bleeding led the patient to develop disseminated intravascular coagulation (DIC), which caused the onset of adult respiratory distress syndrome (ARDS). The defendant contended that the woman never developed DIC. He claimed that the patient’s pre-existing bacterial endocarditis caused aspiration, which resulted in ARDS.

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.

Tarrant County (Tex) District Court—When his patient’s menorrhagia failed to improve with conservative treatment, a gynecologist performed a hysterectomy. Postoperatively, the woman suffered continued blood loss and died 11 weeks later.

The patient’s family sued, claiming that the intractable bleeding led the patient to develop disseminated intravascular coagulation (DIC), which caused the onset of adult respiratory distress syndrome (ARDS). The defendant contended that the woman never developed DIC. He claimed that the patient’s pre-existing bacterial endocarditis caused aspiration, which resulted in ARDS.

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 What is the correct way to code for “shared” surgeries? For example, Dr. A performed an exploratory laparotomy with bilateral salpingo-oophorectomy (BSO), during which he found cancer. Dr. B, a gynecologic oncologist, then performed bilateral pelvic/para-aortic lymph node dissection, peritoneal biopsies, omentectomy, and diaphragmatic scraping.

The diagnosis was serous papillary carcinoma. Dr. B wants to bill 58960 (second-look laparotomy) and 49255 (omentectomy) and have Dr. A bill for the BSO. Would this be accurate?

A Coding for shared surgeries is dictated by the procedures rather than who performed them. Many times, each surgeon will try to bill for his or her individual procedures without taking into account that CPT already may have codes that describe the combination of surgeries performed. In fact, a standard rule for coding is that if it is considered unbundling for 1 physician to itemize procedures described in a single procedure code, it would be considered unbundling for 2 surgeons to do so as well.

Coding for ‘shared’ surgeries is the dictated by the procedures rather than who performed them.

That said, Dr. B’s suggested coding choices would be incorrect. This is because the code for the second-look procedure includes an omentectomy and only a limited lymphadenectomy rather than a bilateral pelvic/para-aortic lymphadenectomy. In fact, none of the codes that apply to the treatment of ovarian cancer include a bilateral pelvic/para-aortic lymph node dissection procedure. Instead, they describe surgical combinations that comprise limited lymphadenectomy or biopsy.

To appropriately code for this particular combination of procedures, both physicians should report 59850-62 to indicate they were co-sur-geons for the bilateral salpingo-oophorectomy for ovarian cancer and omentectomy. In other words, 2 physicians worked together to accomplish distinct parts of a single reportable CPT code. Dr. B also should report code 38770-50-59. Code 38770 represents the pelvic/para-aortic lymph node dissection; the modifier-50 indicates that it was a bilateral procedure; and the modifier-59 states that the lymphadenectomy was distinct from the other procedures performed. If Dr. A assisted with the lymphadenectomy, he also should report code 38770 with the modifier-80 (assuming the surgery was not done on a Medicare patient because Medicare will not allow a physician who is billing as a primary surgeon to bill as an assistant during the same surgical session).

The second, less optimal coding option would be for Dr. A to report only the BSO using 58720 and Dr. B to code for the second-look procedure 58960-22 (unusual procedure). This method may delay payment for Dr. B due to the addition of the modifier-22 for the extra work required by the bilateral pelvic lymphadenectomy. Dr. A also may have difficulty obtaining reimbursement using this method; although he would be billing for a simple BSO, the procedure is linked to a code for cancer. Therefore, the payer may take a closer look at the procedure performed by both surgeons prior to payment.

Finally, the payment implications (using current Medicare relative value units [RVUs] for comparison) are different for these 2 options: The first will maximize reimbursement for Dr. B, while the second will do so for Dr. A.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What is the correct way to code for “shared” surgeries? For example, Dr. A performed an exploratory laparotomy with bilateral salpingo-oophorectomy (BSO), during which he found cancer. Dr. B, a gynecologic oncologist, then performed bilateral pelvic/para-aortic lymph node dissection, peritoneal biopsies, omentectomy, and diaphragmatic scraping.

The diagnosis was serous papillary carcinoma. Dr. B wants to bill 58960 (second-look laparotomy) and 49255 (omentectomy) and have Dr. A bill for the BSO. Would this be accurate?

A Coding for shared surgeries is dictated by the procedures rather than who performed them. Many times, each surgeon will try to bill for his or her individual procedures without taking into account that CPT already may have codes that describe the combination of surgeries performed. In fact, a standard rule for coding is that if it is considered unbundling for 1 physician to itemize procedures described in a single procedure code, it would be considered unbundling for 2 surgeons to do so as well.

Coding for ‘shared’ surgeries is the dictated by the procedures rather than who performed them.

That said, Dr. B’s suggested coding choices would be incorrect. This is because the code for the second-look procedure includes an omentectomy and only a limited lymphadenectomy rather than a bilateral pelvic/para-aortic lymphadenectomy. In fact, none of the codes that apply to the treatment of ovarian cancer include a bilateral pelvic/para-aortic lymph node dissection procedure. Instead, they describe surgical combinations that comprise limited lymphadenectomy or biopsy.

To appropriately code for this particular combination of procedures, both physicians should report 59850-62 to indicate they were co-sur-geons for the bilateral salpingo-oophorectomy for ovarian cancer and omentectomy. In other words, 2 physicians worked together to accomplish distinct parts of a single reportable CPT code. Dr. B also should report code 38770-50-59. Code 38770 represents the pelvic/para-aortic lymph node dissection; the modifier-50 indicates that it was a bilateral procedure; and the modifier-59 states that the lymphadenectomy was distinct from the other procedures performed. If Dr. A assisted with the lymphadenectomy, he also should report code 38770 with the modifier-80 (assuming the surgery was not done on a Medicare patient because Medicare will not allow a physician who is billing as a primary surgeon to bill as an assistant during the same surgical session).

The second, less optimal coding option would be for Dr. A to report only the BSO using 58720 and Dr. B to code for the second-look procedure 58960-22 (unusual procedure). This method may delay payment for Dr. B due to the addition of the modifier-22 for the extra work required by the bilateral pelvic lymphadenectomy. Dr. A also may have difficulty obtaining reimbursement using this method; although he would be billing for a simple BSO, the procedure is linked to a code for cancer. Therefore, the payer may take a closer look at the procedure performed by both surgeons prior to payment.

Finally, the payment implications (using current Medicare relative value units [RVUs] for comparison) are different for these 2 options: The first will maximize reimbursement for Dr. B, while the second will do so for Dr. A.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What is the correct way to code for “shared” surgeries? For example, Dr. A performed an exploratory laparotomy with bilateral salpingo-oophorectomy (BSO), during which he found cancer. Dr. B, a gynecologic oncologist, then performed bilateral pelvic/para-aortic lymph node dissection, peritoneal biopsies, omentectomy, and diaphragmatic scraping.

The diagnosis was serous papillary carcinoma. Dr. B wants to bill 58960 (second-look laparotomy) and 49255 (omentectomy) and have Dr. A bill for the BSO. Would this be accurate?

A Coding for shared surgeries is dictated by the procedures rather than who performed them. Many times, each surgeon will try to bill for his or her individual procedures without taking into account that CPT already may have codes that describe the combination of surgeries performed. In fact, a standard rule for coding is that if it is considered unbundling for 1 physician to itemize procedures described in a single procedure code, it would be considered unbundling for 2 surgeons to do so as well.

Coding for ‘shared’ surgeries is the dictated by the procedures rather than who performed them.

That said, Dr. B’s suggested coding choices would be incorrect. This is because the code for the second-look procedure includes an omentectomy and only a limited lymphadenectomy rather than a bilateral pelvic/para-aortic lymphadenectomy. In fact, none of the codes that apply to the treatment of ovarian cancer include a bilateral pelvic/para-aortic lymph node dissection procedure. Instead, they describe surgical combinations that comprise limited lymphadenectomy or biopsy.

To appropriately code for this particular combination of procedures, both physicians should report 59850-62 to indicate they were co-sur-geons for the bilateral salpingo-oophorectomy for ovarian cancer and omentectomy. In other words, 2 physicians worked together to accomplish distinct parts of a single reportable CPT code. Dr. B also should report code 38770-50-59. Code 38770 represents the pelvic/para-aortic lymph node dissection; the modifier-50 indicates that it was a bilateral procedure; and the modifier-59 states that the lymphadenectomy was distinct from the other procedures performed. If Dr. A assisted with the lymphadenectomy, he also should report code 38770 with the modifier-80 (assuming the surgery was not done on a Medicare patient because Medicare will not allow a physician who is billing as a primary surgeon to bill as an assistant during the same surgical session).

The second, less optimal coding option would be for Dr. A to report only the BSO using 58720 and Dr. B to code for the second-look procedure 58960-22 (unusual procedure). This method may delay payment for Dr. B due to the addition of the modifier-22 for the extra work required by the bilateral pelvic lymphadenectomy. Dr. A also may have difficulty obtaining reimbursement using this method; although he would be billing for a simple BSO, the procedure is linked to a code for cancer. Therefore, the payer may take a closer look at the procedure performed by both surgeons prior to payment.

Finally, the payment implications (using current Medicare relative value units [RVUs] for comparison) are different for these 2 options: The first will maximize reimbursement for Dr. B, while the second will do so for Dr. A.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Physicians often send their patients to our hospital for RhoGAM shots. Why is this happening, and what is the best way to code for this service?

A First, many Ob/Gyns opt not to perform RhoGAM injections in their offices because of exceedingly poor reimbursement from third-party payers. Second, there was a shortage of the product in 1995 and early 1996. In many cases, RhoGAM was available only through local hospitals, so a shift in the site of service took place.

To bill for the injection, select 1 of the following codes: 90384 (Rho[D], IM full dose), 90385 (Rho[D], IM mini-dose), and 90386 (Rho[D], IV use). For example, if a full dose of RhoGAM is administered intra-muscularly to a non-Medicare patient, report codes 90384 and 90782 (therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Some payers will require that you submit the HCPCS level 2 code J2790 (injection, Rho[D] immune globulin, human, one dose package) instead, so always check with the insurer before billing.

To facilitate fair payment, submit the National Drug Code number for the drug and the invoice.

While the coding is standard, reimbursement levels vary from payer to payer. Private payers set their rates for covered drugs based on either reasonable and customary charges, or drug wholesale prices. Many Medicaid and managed care companies, however, set their limits below the market value of the drug. If you believe the payment is unfair, appeal the claim and negotiate with the payer for fair market reimbursement.

To facilitate fair payment, submit both the National Drug Code (NDC) number for the drug, which is located on the package insert and identifies the drug name, manufacturer, and dosage, and the invoice that shows the acquisition cost. (NDC numbers are likely to become the sole method of billing for drugs as a result of HIPPA legislation, which includes a uniform code set, that will be implemented on October 1, 2002.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Physicians often send their patients to our hospital for RhoGAM shots. Why is this happening, and what is the best way to code for this service?

A First, many Ob/Gyns opt not to perform RhoGAM injections in their offices because of exceedingly poor reimbursement from third-party payers. Second, there was a shortage of the product in 1995 and early 1996. In many cases, RhoGAM was available only through local hospitals, so a shift in the site of service took place.

To bill for the injection, select 1 of the following codes: 90384 (Rho[D], IM full dose), 90385 (Rho[D], IM mini-dose), and 90386 (Rho[D], IV use). For example, if a full dose of RhoGAM is administered intra-muscularly to a non-Medicare patient, report codes 90384 and 90782 (therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Some payers will require that you submit the HCPCS level 2 code J2790 (injection, Rho[D] immune globulin, human, one dose package) instead, so always check with the insurer before billing.

To facilitate fair payment, submit the National Drug Code number for the drug and the invoice.

While the coding is standard, reimbursement levels vary from payer to payer. Private payers set their rates for covered drugs based on either reasonable and customary charges, or drug wholesale prices. Many Medicaid and managed care companies, however, set their limits below the market value of the drug. If you believe the payment is unfair, appeal the claim and negotiate with the payer for fair market reimbursement.

To facilitate fair payment, submit both the National Drug Code (NDC) number for the drug, which is located on the package insert and identifies the drug name, manufacturer, and dosage, and the invoice that shows the acquisition cost. (NDC numbers are likely to become the sole method of billing for drugs as a result of HIPPA legislation, which includes a uniform code set, that will be implemented on October 1, 2002.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Physicians often send their patients to our hospital for RhoGAM shots. Why is this happening, and what is the best way to code for this service?

A First, many Ob/Gyns opt not to perform RhoGAM injections in their offices because of exceedingly poor reimbursement from third-party payers. Second, there was a shortage of the product in 1995 and early 1996. In many cases, RhoGAM was available only through local hospitals, so a shift in the site of service took place.

To bill for the injection, select 1 of the following codes: 90384 (Rho[D], IM full dose), 90385 (Rho[D], IM mini-dose), and 90386 (Rho[D], IV use). For example, if a full dose of RhoGAM is administered intra-muscularly to a non-Medicare patient, report codes 90384 and 90782 (therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Some payers will require that you submit the HCPCS level 2 code J2790 (injection, Rho[D] immune globulin, human, one dose package) instead, so always check with the insurer before billing.

To facilitate fair payment, submit the National Drug Code number for the drug and the invoice.

While the coding is standard, reimbursement levels vary from payer to payer. Private payers set their rates for covered drugs based on either reasonable and customary charges, or drug wholesale prices. Many Medicaid and managed care companies, however, set their limits below the market value of the drug. If you believe the payment is unfair, appeal the claim and negotiate with the payer for fair market reimbursement.

To facilitate fair payment, submit both the National Drug Code (NDC) number for the drug, which is located on the package insert and identifies the drug name, manufacturer, and dosage, and the invoice that shows the acquisition cost. (NDC numbers are likely to become the sole method of billing for drugs as a result of HIPPA legislation, which includes a uniform code set, that will be implemented on October 1, 2002.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.

US District Court (Western DISTRICT of Wis)—At 30 weeks’ gestation, a gravida presented to the hospital with lower abdominal discomfort. A nurse examined her, but she received no ultrasound or electronic fetal monitoring, nor was an obstetrician consulted. The woman was instructed to go to a better-equipped medical center if she experienced further pain. Four hours after discharge, the patient presented to the recommended hospital, where she delivered an unresponsive infant via cesarean section. The child died about 10 days later.

In suing, the parents claimed the hospital staff failed to diagnose a partial placental abruption. Also, they said the fetus suffocated during the 4 hours between the examination and the cesarean delivery. The defendant claimed a proper exam was performed and argued an ultrasound would not have diagnosed an abruption. Further, the fetal heart tones were normal, obviating the need for electronic fetal monitoring. Moreover, the defendant asserted the parents were negligent for delaying their presentation to the hospital while the mother’s problems persisted. Ultimately, an intraventricular brain hemorrhage, a complication of preterm delivery, was the cause of the infant’s death, the defense purported.

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.

US District Court (Western DISTRICT of Wis)—At 30 weeks’ gestation, a gravida presented to the hospital with lower abdominal discomfort. A nurse examined her, but she received no ultrasound or electronic fetal monitoring, nor was an obstetrician consulted. The woman was instructed to go to a better-equipped medical center if she experienced further pain. Four hours after discharge, the patient presented to the recommended hospital, where she delivered an unresponsive infant via cesarean section. The child died about 10 days later.

In suing, the parents claimed the hospital staff failed to diagnose a partial placental abruption. Also, they said the fetus suffocated during the 4 hours between the examination and the cesarean delivery. The defendant claimed a proper exam was performed and argued an ultrasound would not have diagnosed an abruption. Further, the fetal heart tones were normal, obviating the need for electronic fetal monitoring. Moreover, the defendant asserted the parents were negligent for delaying their presentation to the hospital while the mother’s problems persisted. Ultimately, an intraventricular brain hemorrhage, a complication of preterm delivery, was the cause of the infant’s death, the defense purported.

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.

US District Court (Western DISTRICT of Wis)—At 30 weeks’ gestation, a gravida presented to the hospital with lower abdominal discomfort. A nurse examined her, but she received no ultrasound or electronic fetal monitoring, nor was an obstetrician consulted. The woman was instructed to go to a better-equipped medical center if she experienced further pain. Four hours after discharge, the patient presented to the recommended hospital, where she delivered an unresponsive infant via cesarean section. The child died about 10 days later.

In suing, the parents claimed the hospital staff failed to diagnose a partial placental abruption. Also, they said the fetus suffocated during the 4 hours between the examination and the cesarean delivery. The defendant claimed a proper exam was performed and argued an ultrasound would not have diagnosed an abruption. Further, the fetal heart tones were normal, obviating the need for electronic fetal monitoring. Moreover, the defendant asserted the parents were negligent for delaying their presentation to the hospital while the mother’s problems persisted. Ultimately, an intraventricular brain hemorrhage, a complication of preterm delivery, was the cause of the infant’s death, the defense purported.

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.