User login
When—and why—was this newborn’s brain injured?
When—and why—was this newborn’s brain injured?
A PREGNANT WOMAN at 34 weeks’ gestation, with a family history of hypertension, experienced swelling of her feet and ankles. She called the midwife prenatal clinic where she was receiving care and was advised to elevate her feet. The next day she called again to report decreased fetal movement, severe edema in her feet and ankles, dizziness, and blurred vision. She was sent to the hospital, where her normal blood pressure and urine protein measurement ruled out preeclampsia. A nonstress test was initially nonreactive and then became reactive, and a biophysical profile score was reassuring. After the results were reported to her certified nurse-midwife, the patient was discharged and instructed to perform fetal kick counts to monitor fetal movement. She was also instructed about preeclampsia. Two weeks later, at 36 weeks’ gestation, she reported contractions, low back pain, headache, and swollen feet and ankles. She was sent to the hospital, where her blood pressure was found to be severely elevated, her urine protein was 3+, and fetal heart tones were nonreassuring. The infant was born 1 hour 14 minutes later by emergency cesarean delivery performed by the ObGyn, who had been delayed by another birth. Mild placental abruption was noted; the child had low Apgar scores, decreased respiratory effort, and low cord blood gases. Diagnoses of birth depression and hypoxic–ischemic encephalopathy were given, and periventricular leukomalacia was evident on head imaging. The child has cognitive deficits and cerebral palsy.
PATIENT’S CLAIM She should have been admitted to the hospital for observation and 24-hour urine testing; then her elevated blood pressure and urine protein level would have been discovered in time for delivery before injury to the infant. Also, because of the nonreassuring fetal monitor tracing, delivery should have been performed earlier that day.
PHYSICIAN’S DEFENSE The fetus was injured in utero a month or more before birth, as periventricular leukomalacia usually occurs at 28 to 32 weeks’ gestation. Also, the patient was properly discharged, because there was no evidence of preeclampsia and the fetal status was reassuring.
VERDICT $1.625 million Michigan settlement.
OB: “Don’t blame me” for faulty IUD placement by nurse
A NURSE UNDER THE SUPERVISION of an obstetrician placed an intrauterine device (IUD) in a patient, but at a follow-up visit the nurse could not see the string of the IUD. Ultrasonography showed the IUD was not in the woman’s uterus. It was removed by laparoscopic surgery.
PATIENT’S CLAIM The nurse placed the IUD incorrectly and, as a result, the uterus was perforated. Also, the physician’s supervision of the nurse was inadequate.
PHYSICIAN’S DEFENSE Not reported.
VERDICT $379,906 Arkansas verdict against the nurse only.
Sexually inactive woman delivers 12-lb stillborn
A 28-YEAR-OLD MORBIDLY OBESE WOMAN presented at the emergency room with low-back pain. Dr. A examined her but could not find a cause for the pain. She then went to Dr. B, an ObGyn, and reported pelvic pain. She admitted having infrequent periods and being sexually inactive. Dr. B performed no pregnancy test and, because of her size, could not palpate the uterus. Dr. A examined her again 10 days later. A few days after that, an x-ray showed a deceased fetus in a breech position. A 12-lb stillborn infant was delivered later that day.
PATIENT’S CLAIM Dr. A and Dr. B were negligent for not diagnosing the pregnancy. Despite her denial of sexual activity, they should have ordered a pregnancy test, which would have discovered the fetus and allowed the birth of a healthy baby. Instead, the fetus died 2 days before delivery.
PHYSICIAN’S DEFENSE Given the history and presentation of the mother, Dr. B claimed his care was reasonable. Also, the fetus died before the mother came to him.
VERDICT Kentucky defense verdict for Dr. B. Before a trial, Dr. A settled for an undisclosed amount.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
When—and why—was this newborn’s brain injured?
A PREGNANT WOMAN at 34 weeks’ gestation, with a family history of hypertension, experienced swelling of her feet and ankles. She called the midwife prenatal clinic where she was receiving care and was advised to elevate her feet. The next day she called again to report decreased fetal movement, severe edema in her feet and ankles, dizziness, and blurred vision. She was sent to the hospital, where her normal blood pressure and urine protein measurement ruled out preeclampsia. A nonstress test was initially nonreactive and then became reactive, and a biophysical profile score was reassuring. After the results were reported to her certified nurse-midwife, the patient was discharged and instructed to perform fetal kick counts to monitor fetal movement. She was also instructed about preeclampsia. Two weeks later, at 36 weeks’ gestation, she reported contractions, low back pain, headache, and swollen feet and ankles. She was sent to the hospital, where her blood pressure was found to be severely elevated, her urine protein was 3+, and fetal heart tones were nonreassuring. The infant was born 1 hour 14 minutes later by emergency cesarean delivery performed by the ObGyn, who had been delayed by another birth. Mild placental abruption was noted; the child had low Apgar scores, decreased respiratory effort, and low cord blood gases. Diagnoses of birth depression and hypoxic–ischemic encephalopathy were given, and periventricular leukomalacia was evident on head imaging. The child has cognitive deficits and cerebral palsy.
PATIENT’S CLAIM She should have been admitted to the hospital for observation and 24-hour urine testing; then her elevated blood pressure and urine protein level would have been discovered in time for delivery before injury to the infant. Also, because of the nonreassuring fetal monitor tracing, delivery should have been performed earlier that day.
PHYSICIAN’S DEFENSE The fetus was injured in utero a month or more before birth, as periventricular leukomalacia usually occurs at 28 to 32 weeks’ gestation. Also, the patient was properly discharged, because there was no evidence of preeclampsia and the fetal status was reassuring.
VERDICT $1.625 million Michigan settlement.
OB: “Don’t blame me” for faulty IUD placement by nurse
A NURSE UNDER THE SUPERVISION of an obstetrician placed an intrauterine device (IUD) in a patient, but at a follow-up visit the nurse could not see the string of the IUD. Ultrasonography showed the IUD was not in the woman’s uterus. It was removed by laparoscopic surgery.
PATIENT’S CLAIM The nurse placed the IUD incorrectly and, as a result, the uterus was perforated. Also, the physician’s supervision of the nurse was inadequate.
PHYSICIAN’S DEFENSE Not reported.
VERDICT $379,906 Arkansas verdict against the nurse only.
Sexually inactive woman delivers 12-lb stillborn
A 28-YEAR-OLD MORBIDLY OBESE WOMAN presented at the emergency room with low-back pain. Dr. A examined her but could not find a cause for the pain. She then went to Dr. B, an ObGyn, and reported pelvic pain. She admitted having infrequent periods and being sexually inactive. Dr. B performed no pregnancy test and, because of her size, could not palpate the uterus. Dr. A examined her again 10 days later. A few days after that, an x-ray showed a deceased fetus in a breech position. A 12-lb stillborn infant was delivered later that day.
PATIENT’S CLAIM Dr. A and Dr. B were negligent for not diagnosing the pregnancy. Despite her denial of sexual activity, they should have ordered a pregnancy test, which would have discovered the fetus and allowed the birth of a healthy baby. Instead, the fetus died 2 days before delivery.
PHYSICIAN’S DEFENSE Given the history and presentation of the mother, Dr. B claimed his care was reasonable. Also, the fetus died before the mother came to him.
VERDICT Kentucky defense verdict for Dr. B. Before a trial, Dr. A settled for an undisclosed amount.
When—and why—was this newborn’s brain injured?
A PREGNANT WOMAN at 34 weeks’ gestation, with a family history of hypertension, experienced swelling of her feet and ankles. She called the midwife prenatal clinic where she was receiving care and was advised to elevate her feet. The next day she called again to report decreased fetal movement, severe edema in her feet and ankles, dizziness, and blurred vision. She was sent to the hospital, where her normal blood pressure and urine protein measurement ruled out preeclampsia. A nonstress test was initially nonreactive and then became reactive, and a biophysical profile score was reassuring. After the results were reported to her certified nurse-midwife, the patient was discharged and instructed to perform fetal kick counts to monitor fetal movement. She was also instructed about preeclampsia. Two weeks later, at 36 weeks’ gestation, she reported contractions, low back pain, headache, and swollen feet and ankles. She was sent to the hospital, where her blood pressure was found to be severely elevated, her urine protein was 3+, and fetal heart tones were nonreassuring. The infant was born 1 hour 14 minutes later by emergency cesarean delivery performed by the ObGyn, who had been delayed by another birth. Mild placental abruption was noted; the child had low Apgar scores, decreased respiratory effort, and low cord blood gases. Diagnoses of birth depression and hypoxic–ischemic encephalopathy were given, and periventricular leukomalacia was evident on head imaging. The child has cognitive deficits and cerebral palsy.
PATIENT’S CLAIM She should have been admitted to the hospital for observation and 24-hour urine testing; then her elevated blood pressure and urine protein level would have been discovered in time for delivery before injury to the infant. Also, because of the nonreassuring fetal monitor tracing, delivery should have been performed earlier that day.
PHYSICIAN’S DEFENSE The fetus was injured in utero a month or more before birth, as periventricular leukomalacia usually occurs at 28 to 32 weeks’ gestation. Also, the patient was properly discharged, because there was no evidence of preeclampsia and the fetal status was reassuring.
VERDICT $1.625 million Michigan settlement.
OB: “Don’t blame me” for faulty IUD placement by nurse
A NURSE UNDER THE SUPERVISION of an obstetrician placed an intrauterine device (IUD) in a patient, but at a follow-up visit the nurse could not see the string of the IUD. Ultrasonography showed the IUD was not in the woman’s uterus. It was removed by laparoscopic surgery.
PATIENT’S CLAIM The nurse placed the IUD incorrectly and, as a result, the uterus was perforated. Also, the physician’s supervision of the nurse was inadequate.
PHYSICIAN’S DEFENSE Not reported.
VERDICT $379,906 Arkansas verdict against the nurse only.
Sexually inactive woman delivers 12-lb stillborn
A 28-YEAR-OLD MORBIDLY OBESE WOMAN presented at the emergency room with low-back pain. Dr. A examined her but could not find a cause for the pain. She then went to Dr. B, an ObGyn, and reported pelvic pain. She admitted having infrequent periods and being sexually inactive. Dr. B performed no pregnancy test and, because of her size, could not palpate the uterus. Dr. A examined her again 10 days later. A few days after that, an x-ray showed a deceased fetus in a breech position. A 12-lb stillborn infant was delivered later that day.
PATIENT’S CLAIM Dr. A and Dr. B were negligent for not diagnosing the pregnancy. Despite her denial of sexual activity, they should have ordered a pregnancy test, which would have discovered the fetus and allowed the birth of a healthy baby. Instead, the fetus died 2 days before delivery.
PHYSICIAN’S DEFENSE Given the history and presentation of the mother, Dr. B claimed his care was reasonable. Also, the fetus died before the mother came to him.
VERDICT Kentucky defense verdict for Dr. B. Before a trial, Dr. A settled for an undisclosed amount.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Making Learning Fun
Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.
Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.
Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.
This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.
Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.
Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?
As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.
An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.
Think of it as the “Schoch Letter” on amphetamines.
Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.
When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.
When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.
We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.
There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.
Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.
Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.
This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.
Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.
Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?
As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.
An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.
Think of it as the “Schoch Letter” on amphetamines.
Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.
When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.
When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.
We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.
There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.
Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.
Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.
This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.
Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.
Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?
As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.
An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.
Think of it as the “Schoch Letter” on amphetamines.
Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.
When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.
When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.
We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.
There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Watch Out for Embezzlers
Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.
A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.
The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.
“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:
▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com
▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.
▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.
▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.
▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.
▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.
▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?
▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.
Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.
A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.
The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.
“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:
▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com
▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.
▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.
▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.
▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.
▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.
▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?
▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.
Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.
A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.
The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.
“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.
Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:
▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com
▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.
▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.
▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.
▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.
▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.
▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?
▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.
Facility Transfers
Patient care provided in the acute setting might not always end with discharge to the patient’s home. Frequently, a hospitalist will transfer the patient to a different unit in the hospital or an off-site facility to receive additional services before returning to their home. When the patient’s condition requires a transfer to a physical medicine and rehabilitation (PM&R) unit, a psychiatric unit, a long-term acute-care facility, or a skilled nursing facility, it is important for the hospitalist to identify their role, if any, in the new area of care. Physician billing will depend on several factors:
- A shared medical record;
- The attending of record in each setting; and
- The care rendered by the hospitalist in each setting.
Intrafacility
A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for a 68-year-old male with hypertension and diabetes who sustained a hip fracture. The care plan includes post-discharge therapy and rehabilitation. When the hospitalist transfers care to a PM&R unit within the same facility for which the hospitalist is no longer the attending of record, they might be asked to provide ongoing care for the patient’s medical conditions (e.g., diabetes and hypertension). The hospitalist’s knee-jerk reaction is to bill for an inpatient consultation for the initial service provided in the transferred setting. This would only be appropriate if the request for opinion or advice involved an unrelated, new condition, and the requesting physician’s intent is for opinion or advice on how to manage the patient and not the a priori intent for the hospitalist to assume the patient’s medical care.
If consultation requirements are met (see “Consulataion Reminder,” p. 20), the hospitalist can report an inpatient consultation code (99251-99255). However, when circumstances do not fully represent the intent or need for consultative services but rather a continuity of the medical care provided during the acute phase of the hospitalization, report the most appropriate subsequent hospital care code (99231-99233) for the initial rehab visit and all follow-up services.
On occasion, the hospitalist will be asked to perform and provide the history and physical (H&P) for the patient’s “sub-acute” phase of care, even though the hospitalist is not the attending of record. This usually happens when the attending of record cannot complete the medical requirements of the H&P, either at all or as comprehensively as the hospitalist. When this occurs, the hospitalist should not report an initial hospital care code (99221-99223) because they are not the attending of record—the physician who admits the patient and is responsible for the patient’s stay in the transferred location.
Additionally, a consultation service (99251-99255) should not be reported, because the request involves the completion of a facility-mandated form and not an opinion or advice on caring for the patient. If medical issues require the hospitalist’s evaluation and management, there is medical necessity for capturing the hospitalist’s participation as subsequent hospital care (99231-99233). If no medical conditions present for the hospitalist to manage, the service will not be considered “medically necessary” by the payor.
Interfacility
Hospitalist groups provide patient care and coverage in a variety of facilities. Confusion often arises when the attending of record during acute care and the sub-acute setting are different hospitalists from the same HM group. The hospitalist who receives the patient in the transfer facility may err on the side of caution and report subsequent hospital care (99231-99233) because the group has provided ongoing patient care. In this scenario, the hospitalist group might lose revenue if an admission service (99221-99223) was not reported.
Day of Transfer Billing
A single hospitalist or two hospitalists from the same group might bill both the hospital discharge management code (99238-99239) and an initial hospital care code (99221-99223) when the discharge and admission do not occur on the same day if the transfer is between:
- Different hospitals;
- Different facilities under common ownership that do not have merged records;* or
- Between the acute-care hospital and a prospective payment system (PPS)-exempt unit within the same hospital when there are no merged records.
In all other transfer circumstances that do not meet the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.1 Of note, Medicare Part A covers inpatient care in psychiatric, rehabilitation, critical access, and long-term-care hospitals. Each of these specialty hospitals is exempt from the PPS established for acute-care hospitals in 1983.2 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
*Editor’s note: “Merged record” is not equivalent to commonly accessible charts via an electronic health record system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.
References
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1E. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
- Department of Health and Human Services. Office of Inspector General: Oversight of Medicare PPS-Exempt Hospital Services. HHS Web site. Available at: www.oig.hhs.gov/oei/reports/oei-12-02-00170.pdf. Accessed June 1, 2009.
- CMS. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1H. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
Patient care provided in the acute setting might not always end with discharge to the patient’s home. Frequently, a hospitalist will transfer the patient to a different unit in the hospital or an off-site facility to receive additional services before returning to their home. When the patient’s condition requires a transfer to a physical medicine and rehabilitation (PM&R) unit, a psychiatric unit, a long-term acute-care facility, or a skilled nursing facility, it is important for the hospitalist to identify their role, if any, in the new area of care. Physician billing will depend on several factors:
- A shared medical record;
- The attending of record in each setting; and
- The care rendered by the hospitalist in each setting.
Intrafacility
A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for a 68-year-old male with hypertension and diabetes who sustained a hip fracture. The care plan includes post-discharge therapy and rehabilitation. When the hospitalist transfers care to a PM&R unit within the same facility for which the hospitalist is no longer the attending of record, they might be asked to provide ongoing care for the patient’s medical conditions (e.g., diabetes and hypertension). The hospitalist’s knee-jerk reaction is to bill for an inpatient consultation for the initial service provided in the transferred setting. This would only be appropriate if the request for opinion or advice involved an unrelated, new condition, and the requesting physician’s intent is for opinion or advice on how to manage the patient and not the a priori intent for the hospitalist to assume the patient’s medical care.
If consultation requirements are met (see “Consulataion Reminder,” p. 20), the hospitalist can report an inpatient consultation code (99251-99255). However, when circumstances do not fully represent the intent or need for consultative services but rather a continuity of the medical care provided during the acute phase of the hospitalization, report the most appropriate subsequent hospital care code (99231-99233) for the initial rehab visit and all follow-up services.
On occasion, the hospitalist will be asked to perform and provide the history and physical (H&P) for the patient’s “sub-acute” phase of care, even though the hospitalist is not the attending of record. This usually happens when the attending of record cannot complete the medical requirements of the H&P, either at all or as comprehensively as the hospitalist. When this occurs, the hospitalist should not report an initial hospital care code (99221-99223) because they are not the attending of record—the physician who admits the patient and is responsible for the patient’s stay in the transferred location.
Additionally, a consultation service (99251-99255) should not be reported, because the request involves the completion of a facility-mandated form and not an opinion or advice on caring for the patient. If medical issues require the hospitalist’s evaluation and management, there is medical necessity for capturing the hospitalist’s participation as subsequent hospital care (99231-99233). If no medical conditions present for the hospitalist to manage, the service will not be considered “medically necessary” by the payor.
Interfacility
Hospitalist groups provide patient care and coverage in a variety of facilities. Confusion often arises when the attending of record during acute care and the sub-acute setting are different hospitalists from the same HM group. The hospitalist who receives the patient in the transfer facility may err on the side of caution and report subsequent hospital care (99231-99233) because the group has provided ongoing patient care. In this scenario, the hospitalist group might lose revenue if an admission service (99221-99223) was not reported.
Day of Transfer Billing
A single hospitalist or two hospitalists from the same group might bill both the hospital discharge management code (99238-99239) and an initial hospital care code (99221-99223) when the discharge and admission do not occur on the same day if the transfer is between:
- Different hospitals;
- Different facilities under common ownership that do not have merged records;* or
- Between the acute-care hospital and a prospective payment system (PPS)-exempt unit within the same hospital when there are no merged records.
In all other transfer circumstances that do not meet the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.1 Of note, Medicare Part A covers inpatient care in psychiatric, rehabilitation, critical access, and long-term-care hospitals. Each of these specialty hospitals is exempt from the PPS established for acute-care hospitals in 1983.2 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
*Editor’s note: “Merged record” is not equivalent to commonly accessible charts via an electronic health record system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.
References
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1E. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
- Department of Health and Human Services. Office of Inspector General: Oversight of Medicare PPS-Exempt Hospital Services. HHS Web site. Available at: www.oig.hhs.gov/oei/reports/oei-12-02-00170.pdf. Accessed June 1, 2009.
- CMS. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1H. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
Patient care provided in the acute setting might not always end with discharge to the patient’s home. Frequently, a hospitalist will transfer the patient to a different unit in the hospital or an off-site facility to receive additional services before returning to their home. When the patient’s condition requires a transfer to a physical medicine and rehabilitation (PM&R) unit, a psychiatric unit, a long-term acute-care facility, or a skilled nursing facility, it is important for the hospitalist to identify their role, if any, in the new area of care. Physician billing will depend on several factors:
- A shared medical record;
- The attending of record in each setting; and
- The care rendered by the hospitalist in each setting.
Intrafacility
A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for a 68-year-old male with hypertension and diabetes who sustained a hip fracture. The care plan includes post-discharge therapy and rehabilitation. When the hospitalist transfers care to a PM&R unit within the same facility for which the hospitalist is no longer the attending of record, they might be asked to provide ongoing care for the patient’s medical conditions (e.g., diabetes and hypertension). The hospitalist’s knee-jerk reaction is to bill for an inpatient consultation for the initial service provided in the transferred setting. This would only be appropriate if the request for opinion or advice involved an unrelated, new condition, and the requesting physician’s intent is for opinion or advice on how to manage the patient and not the a priori intent for the hospitalist to assume the patient’s medical care.
If consultation requirements are met (see “Consulataion Reminder,” p. 20), the hospitalist can report an inpatient consultation code (99251-99255). However, when circumstances do not fully represent the intent or need for consultative services but rather a continuity of the medical care provided during the acute phase of the hospitalization, report the most appropriate subsequent hospital care code (99231-99233) for the initial rehab visit and all follow-up services.
On occasion, the hospitalist will be asked to perform and provide the history and physical (H&P) for the patient’s “sub-acute” phase of care, even though the hospitalist is not the attending of record. This usually happens when the attending of record cannot complete the medical requirements of the H&P, either at all or as comprehensively as the hospitalist. When this occurs, the hospitalist should not report an initial hospital care code (99221-99223) because they are not the attending of record—the physician who admits the patient and is responsible for the patient’s stay in the transferred location.
Additionally, a consultation service (99251-99255) should not be reported, because the request involves the completion of a facility-mandated form and not an opinion or advice on caring for the patient. If medical issues require the hospitalist’s evaluation and management, there is medical necessity for capturing the hospitalist’s participation as subsequent hospital care (99231-99233). If no medical conditions present for the hospitalist to manage, the service will not be considered “medically necessary” by the payor.
Interfacility
Hospitalist groups provide patient care and coverage in a variety of facilities. Confusion often arises when the attending of record during acute care and the sub-acute setting are different hospitalists from the same HM group. The hospitalist who receives the patient in the transfer facility may err on the side of caution and report subsequent hospital care (99231-99233) because the group has provided ongoing patient care. In this scenario, the hospitalist group might lose revenue if an admission service (99221-99223) was not reported.
Day of Transfer Billing
A single hospitalist or two hospitalists from the same group might bill both the hospital discharge management code (99238-99239) and an initial hospital care code (99221-99223) when the discharge and admission do not occur on the same day if the transfer is between:
- Different hospitals;
- Different facilities under common ownership that do not have merged records;* or
- Between the acute-care hospital and a prospective payment system (PPS)-exempt unit within the same hospital when there are no merged records.
In all other transfer circumstances that do not meet the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.1 Of note, Medicare Part A covers inpatient care in psychiatric, rehabilitation, critical access, and long-term-care hospitals. Each of these specialty hospitals is exempt from the PPS established for acute-care hospitals in 1983.2 TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
*Editor’s note: “Merged record” is not equivalent to commonly accessible charts via an electronic health record system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.
References
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1E. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
- Department of Health and Human Services. Office of Inspector General: Oversight of Medicare PPS-Exempt Hospital Services. HHS Web site. Available at: www.oig.hhs.gov/oei/reports/oei-12-02-00170.pdf. Accessed June 1, 2009.
- CMS. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1H. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed June 1, 2009.
Medical Verdicts
Cyst is discovered when it weighs 7 lb
A 22-YEAR-OLD WOMAN underwent two examinations within a year, both performed by her ObGyn. She did not report abdominal problems, and none were found. Four months after the second exam, she was discovered to have a huge dermoid ovarian cyst—30 cm by 20 cm by 10 cm, and weighing over 7 lb. It required surgery, which included an appendectomy and salpingo-oophorectomy.
PATIENT’S CLAIM The cyst should have been discovered during the first examination, and then less invasive procedures would have been needed.
PHYSICIAN’S DEFENSE The cyst could not be detected in the first exam, and the patient did not report abdominal problems at the second exam. Her treatment and outcome were not changed by a delay in diagnosis.
VERDICT New York defense verdict.
ObGyn: “I never said I nicked the bladder”
FOLLOWING A HYSTERECTOMY performed by an ObGyn employed by a government-run facility, a patient suffered incontinence and other urinary problems. She was referred to a urologist, who diagnosed a vesicovaginal fistula. The fistula was successfully repaired surgically.
PATIENT’S CLAIM The ObGyn admitted nicking the bladder, but believed it would heal on its own. She was negligent for causing the bladder injury and for not repairing it immediately. Also, the surgical note was dictated 18 days following the procedure.
PHYSICIAN’S DEFENSE The ObGyn denied the patient’s first claim. Also, the injury did not occur during surgery, but later, when the bladder wall broke down as a result of postsurgical denervation. If there had been a bladder injury, problems would have been apparent immediately, but in fact the patient’s initial urine counts were good.
VERDICT Kentucky defense verdict.
Oxytocin is given—but baby is breech
A WOMAN PREGNANT with her fifth child presented at the hospital for delivery. A vaginal exam performed by a nurse indicated 1 cm dilation, -3 to -4 station, and 40% effaced. This was reported over the phone to Dr. A, her OB, who then ordered oxytocin. Oxytocin was administered without the nurses determining the fetus’s presentation. When they could not get a reliable reading of the fetal heart tone, they placed a fetal scalp electrode. It showed a nonreassuring fetal heart pattern. Ten minutes later, the fetus was bradycardic, but Dr. A was not called immediately. Dr. B, a second OB, examined the patient 17 minutes later and ordered an immediate cesarean delivery. The fetus was found in the breech position with significant placental abruption—and the fetal scalp electrode was attached on the buttocks, not the head. The baby was born severely depressed—limp, pale, with no cry or movement. He was resuscitated, but a CT scan indicated hypoxic–ischemic brain damage.
PATIENT’S CLAIM Dr. A failed to examine her to determine the presentation, which he should have done before ordering oxytocin. The nurses failed to communicate with him about the presentation and administered oxytocin without documentation of the presentation.
PHYSICIAN’S DEFENSE The nurse indicated the baby was in the vertex position. If he had known it was a breech presentation, he would not have ordered oxytocin, would not have gone for a trial of labor, and would have proceeded directly to a cesarean delivery.
VERDICT $12 million Illinois settlement.
Mother wasn’t admitted for bed rest, and baby is injured
TOWARD THE END OF HER PREGNANCY, a woman was given a diagnosis of pregnancy-induced hypertension. Over the next 2 weeks, she developed pedal edema, elevated blood pressure, and headaches. She was sent to Dr. C for a possible cesarean delivery. He ordered testing to rule out pregnancy-induced hypertension and recommended bed rest and close observation of the blood pressure. A week later, she suffered placental abruption. At the hospital, she delivered an infant born with severe asphyxia. The resulting hypoxic–ischemic encephalopathy caused the child’s death at 5 months.
PATIENT’S CLAIM Dr. C should have admitted her to the hospital to ensure strict bed rest and monitoring of her blood pressure—and also should have ordered a nonstress test.
PHYSICIAN’S DEFENSE There was no negligence.
VERDICT $350,000 Michigan settlement.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Cyst is discovered when it weighs 7 lb
A 22-YEAR-OLD WOMAN underwent two examinations within a year, both performed by her ObGyn. She did not report abdominal problems, and none were found. Four months after the second exam, she was discovered to have a huge dermoid ovarian cyst—30 cm by 20 cm by 10 cm, and weighing over 7 lb. It required surgery, which included an appendectomy and salpingo-oophorectomy.
PATIENT’S CLAIM The cyst should have been discovered during the first examination, and then less invasive procedures would have been needed.
PHYSICIAN’S DEFENSE The cyst could not be detected in the first exam, and the patient did not report abdominal problems at the second exam. Her treatment and outcome were not changed by a delay in diagnosis.
VERDICT New York defense verdict.
ObGyn: “I never said I nicked the bladder”
FOLLOWING A HYSTERECTOMY performed by an ObGyn employed by a government-run facility, a patient suffered incontinence and other urinary problems. She was referred to a urologist, who diagnosed a vesicovaginal fistula. The fistula was successfully repaired surgically.
PATIENT’S CLAIM The ObGyn admitted nicking the bladder, but believed it would heal on its own. She was negligent for causing the bladder injury and for not repairing it immediately. Also, the surgical note was dictated 18 days following the procedure.
PHYSICIAN’S DEFENSE The ObGyn denied the patient’s first claim. Also, the injury did not occur during surgery, but later, when the bladder wall broke down as a result of postsurgical denervation. If there had been a bladder injury, problems would have been apparent immediately, but in fact the patient’s initial urine counts were good.
VERDICT Kentucky defense verdict.
Oxytocin is given—but baby is breech
A WOMAN PREGNANT with her fifth child presented at the hospital for delivery. A vaginal exam performed by a nurse indicated 1 cm dilation, -3 to -4 station, and 40% effaced. This was reported over the phone to Dr. A, her OB, who then ordered oxytocin. Oxytocin was administered without the nurses determining the fetus’s presentation. When they could not get a reliable reading of the fetal heart tone, they placed a fetal scalp electrode. It showed a nonreassuring fetal heart pattern. Ten minutes later, the fetus was bradycardic, but Dr. A was not called immediately. Dr. B, a second OB, examined the patient 17 minutes later and ordered an immediate cesarean delivery. The fetus was found in the breech position with significant placental abruption—and the fetal scalp electrode was attached on the buttocks, not the head. The baby was born severely depressed—limp, pale, with no cry or movement. He was resuscitated, but a CT scan indicated hypoxic–ischemic brain damage.
PATIENT’S CLAIM Dr. A failed to examine her to determine the presentation, which he should have done before ordering oxytocin. The nurses failed to communicate with him about the presentation and administered oxytocin without documentation of the presentation.
PHYSICIAN’S DEFENSE The nurse indicated the baby was in the vertex position. If he had known it was a breech presentation, he would not have ordered oxytocin, would not have gone for a trial of labor, and would have proceeded directly to a cesarean delivery.
VERDICT $12 million Illinois settlement.
Mother wasn’t admitted for bed rest, and baby is injured
TOWARD THE END OF HER PREGNANCY, a woman was given a diagnosis of pregnancy-induced hypertension. Over the next 2 weeks, she developed pedal edema, elevated blood pressure, and headaches. She was sent to Dr. C for a possible cesarean delivery. He ordered testing to rule out pregnancy-induced hypertension and recommended bed rest and close observation of the blood pressure. A week later, she suffered placental abruption. At the hospital, she delivered an infant born with severe asphyxia. The resulting hypoxic–ischemic encephalopathy caused the child’s death at 5 months.
PATIENT’S CLAIM Dr. C should have admitted her to the hospital to ensure strict bed rest and monitoring of her blood pressure—and also should have ordered a nonstress test.
PHYSICIAN’S DEFENSE There was no negligence.
VERDICT $350,000 Michigan settlement.
Cyst is discovered when it weighs 7 lb
A 22-YEAR-OLD WOMAN underwent two examinations within a year, both performed by her ObGyn. She did not report abdominal problems, and none were found. Four months after the second exam, she was discovered to have a huge dermoid ovarian cyst—30 cm by 20 cm by 10 cm, and weighing over 7 lb. It required surgery, which included an appendectomy and salpingo-oophorectomy.
PATIENT’S CLAIM The cyst should have been discovered during the first examination, and then less invasive procedures would have been needed.
PHYSICIAN’S DEFENSE The cyst could not be detected in the first exam, and the patient did not report abdominal problems at the second exam. Her treatment and outcome were not changed by a delay in diagnosis.
VERDICT New York defense verdict.
ObGyn: “I never said I nicked the bladder”
FOLLOWING A HYSTERECTOMY performed by an ObGyn employed by a government-run facility, a patient suffered incontinence and other urinary problems. She was referred to a urologist, who diagnosed a vesicovaginal fistula. The fistula was successfully repaired surgically.
PATIENT’S CLAIM The ObGyn admitted nicking the bladder, but believed it would heal on its own. She was negligent for causing the bladder injury and for not repairing it immediately. Also, the surgical note was dictated 18 days following the procedure.
PHYSICIAN’S DEFENSE The ObGyn denied the patient’s first claim. Also, the injury did not occur during surgery, but later, when the bladder wall broke down as a result of postsurgical denervation. If there had been a bladder injury, problems would have been apparent immediately, but in fact the patient’s initial urine counts were good.
VERDICT Kentucky defense verdict.
Oxytocin is given—but baby is breech
A WOMAN PREGNANT with her fifth child presented at the hospital for delivery. A vaginal exam performed by a nurse indicated 1 cm dilation, -3 to -4 station, and 40% effaced. This was reported over the phone to Dr. A, her OB, who then ordered oxytocin. Oxytocin was administered without the nurses determining the fetus’s presentation. When they could not get a reliable reading of the fetal heart tone, they placed a fetal scalp electrode. It showed a nonreassuring fetal heart pattern. Ten minutes later, the fetus was bradycardic, but Dr. A was not called immediately. Dr. B, a second OB, examined the patient 17 minutes later and ordered an immediate cesarean delivery. The fetus was found in the breech position with significant placental abruption—and the fetal scalp electrode was attached on the buttocks, not the head. The baby was born severely depressed—limp, pale, with no cry or movement. He was resuscitated, but a CT scan indicated hypoxic–ischemic brain damage.
PATIENT’S CLAIM Dr. A failed to examine her to determine the presentation, which he should have done before ordering oxytocin. The nurses failed to communicate with him about the presentation and administered oxytocin without documentation of the presentation.
PHYSICIAN’S DEFENSE The nurse indicated the baby was in the vertex position. If he had known it was a breech presentation, he would not have ordered oxytocin, would not have gone for a trial of labor, and would have proceeded directly to a cesarean delivery.
VERDICT $12 million Illinois settlement.
Mother wasn’t admitted for bed rest, and baby is injured
TOWARD THE END OF HER PREGNANCY, a woman was given a diagnosis of pregnancy-induced hypertension. Over the next 2 weeks, she developed pedal edema, elevated blood pressure, and headaches. She was sent to Dr. C for a possible cesarean delivery. He ordered testing to rule out pregnancy-induced hypertension and recommended bed rest and close observation of the blood pressure. A week later, she suffered placental abruption. At the hospital, she delivered an infant born with severe asphyxia. The resulting hypoxic–ischemic encephalopathy caused the child’s death at 5 months.
PATIENT’S CLAIM Dr. C should have admitted her to the hospital to ensure strict bed rest and monitoring of her blood pressure—and also should have ordered a nonstress test.
PHYSICIAN’S DEFENSE There was no negligence.
VERDICT $350,000 Michigan settlement.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
That time of year: Turn back the clock, watch H1N1 flu return, and adopt a new ICD-9 code set
Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.
In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.
On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:
- visits and procedures for fertility preservation
- inconclusive mammography
- preprocedural laboratory testing.
Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!
Changes to obstetric codes
PUERPERAL INFECTIONS
Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.
Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).
670.1x [0,2,4] Puerperal endometritis
670.2x [0,2,4] Puerperal sepsis
670.3x [0,2,4] Puerperal septic thrombophlebitis
670.8x [0,2,4] Other major puerperal infection
VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM
Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.
For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.
Gyn code changes
HYPERPLASIA
Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.
In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.
ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.
A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.
An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.
621.34 Benign endometrial hyperplasia
621.35 Endometrial intraepithelial neoplasia
Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.
Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.
Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.
793.82 Inconclusive mammogram
FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY
Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.
The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:
- conception before cancer treatment
- banking of sperm, eggs, ovarian tissue, and embryos
- protecting the ovaries during radiation therapy
- modifying surgery to spare the uterus.
V26.42 Encounter for fertility preservation counseling
V26.82 Encounter for fertility preservation procedure
PREPROCEDURAL EVALUATIONS
Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.
For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.
ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.
Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.
V72.60 Laboratory examination, unspecified
V72.61 Antibody response examination
V72.62 Laboratory examination ordered as part of a routine general medical examination
V72.63 Preprocedural laboratory examination
V72.69 Other laboratory examination
PERSONAL HISTORY CODES
A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.
Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.
V87.43 Personal history of estrogen therapy
V87.44 Personal history of inhaled steroid therapy
V87.45 Personal history of systemic steroid therapy
V87.46 Personal history of immunosuppressive therapy
Plus a number of miscellaneous additions and changes
Here are few more new codes that may better explain why you saw a patient, provided:
- the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
- the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
995.24 Failed moderate sedation during procedure
V10.90 Personal history of unspecified type of malignant neoplasm
V15.80 Personal history of failed moderate sedation
V61.07 Family disruption due to death of family member
V61.08 Family disruption due to other extended absence of a family member
V61.42 Substance abuse in family
Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.
In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.
On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:
- visits and procedures for fertility preservation
- inconclusive mammography
- preprocedural laboratory testing.
Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!
Changes to obstetric codes
PUERPERAL INFECTIONS
Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.
Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).
670.1x [0,2,4] Puerperal endometritis
670.2x [0,2,4] Puerperal sepsis
670.3x [0,2,4] Puerperal septic thrombophlebitis
670.8x [0,2,4] Other major puerperal infection
VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM
Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.
For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.
Gyn code changes
HYPERPLASIA
Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.
In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.
ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.
A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.
An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.
621.34 Benign endometrial hyperplasia
621.35 Endometrial intraepithelial neoplasia
Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.
Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.
Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.
793.82 Inconclusive mammogram
FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY
Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.
The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:
- conception before cancer treatment
- banking of sperm, eggs, ovarian tissue, and embryos
- protecting the ovaries during radiation therapy
- modifying surgery to spare the uterus.
V26.42 Encounter for fertility preservation counseling
V26.82 Encounter for fertility preservation procedure
PREPROCEDURAL EVALUATIONS
Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.
For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.
ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.
Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.
V72.60 Laboratory examination, unspecified
V72.61 Antibody response examination
V72.62 Laboratory examination ordered as part of a routine general medical examination
V72.63 Preprocedural laboratory examination
V72.69 Other laboratory examination
PERSONAL HISTORY CODES
A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.
Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.
V87.43 Personal history of estrogen therapy
V87.44 Personal history of inhaled steroid therapy
V87.45 Personal history of systemic steroid therapy
V87.46 Personal history of immunosuppressive therapy
Plus a number of miscellaneous additions and changes
Here are few more new codes that may better explain why you saw a patient, provided:
- the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
- the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
995.24 Failed moderate sedation during procedure
V10.90 Personal history of unspecified type of malignant neoplasm
V15.80 Personal history of failed moderate sedation
V61.07 Family disruption due to death of family member
V61.08 Family disruption due to other extended absence of a family member
V61.42 Substance abuse in family
Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.
In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.
On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:
- visits and procedures for fertility preservation
- inconclusive mammography
- preprocedural laboratory testing.
Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!
Changes to obstetric codes
PUERPERAL INFECTIONS
Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.
Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).
670.1x [0,2,4] Puerperal endometritis
670.2x [0,2,4] Puerperal sepsis
670.3x [0,2,4] Puerperal septic thrombophlebitis
670.8x [0,2,4] Other major puerperal infection
VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM
Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.
For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.
Gyn code changes
HYPERPLASIA
Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.
In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.
ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.
A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.
An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.
621.34 Benign endometrial hyperplasia
621.35 Endometrial intraepithelial neoplasia
Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.
Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.
Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.
793.82 Inconclusive mammogram
FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY
Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.
The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:
- conception before cancer treatment
- banking of sperm, eggs, ovarian tissue, and embryos
- protecting the ovaries during radiation therapy
- modifying surgery to spare the uterus.
V26.42 Encounter for fertility preservation counseling
V26.82 Encounter for fertility preservation procedure
PREPROCEDURAL EVALUATIONS
Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.
For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.
ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.
Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.
V72.60 Laboratory examination, unspecified
V72.61 Antibody response examination
V72.62 Laboratory examination ordered as part of a routine general medical examination
V72.63 Preprocedural laboratory examination
V72.69 Other laboratory examination
PERSONAL HISTORY CODES
A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.
Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.
V87.43 Personal history of estrogen therapy
V87.44 Personal history of inhaled steroid therapy
V87.45 Personal history of systemic steroid therapy
V87.46 Personal history of immunosuppressive therapy
Plus a number of miscellaneous additions and changes
Here are few more new codes that may better explain why you saw a patient, provided:
- the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
- the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
995.24 Failed moderate sedation during procedure
V10.90 Personal history of unspecified type of malignant neoplasm
V15.80 Personal history of failed moderate sedation
V61.07 Family disruption due to death of family member
V61.08 Family disruption due to other extended absence of a family member
V61.42 Substance abuse in family
Invest in Yourself
You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.
Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.
Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”
Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.
You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.
Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.
I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”
Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.
I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.
That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.
Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.
And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.
Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.
Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.
The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.
Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.
And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.
Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.
Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”
Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.
You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.
Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.
I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”
Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.
I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.
That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.
Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.
And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.
Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.
Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.
The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.
Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.
And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.
Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.
Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”
Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.
You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.
Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.
I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”
Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.
I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.
That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.
Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.
And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.
Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.
Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.
The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.
Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.
And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”
To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com
Investigate Claim Denials
In order to recover the appropriate payment for services provided by hospitalists, the following must occur:
- The billing provider renders service fully, or jointly with a resident under the teaching physician guidelines or nonphysician provider under the shared/split billing rules;
- The service is completely and accurately documented in the medical record;
- The correct information is entered on the claim form that is submitted to the payor; and
- The service is determined to be a covered benefit and eligible for payment.
Claims frequently are rejected or denied. Even more frequently, the physician or billing staff does not understand the reason for the denial. The typical reaction to claim denial is twofold: “appeal with paper” and “write off.” In other words, send a copy of the physician notes to the payor and consider the claim unsuccessful and payment unable to be obtained.
Examining and understanding the payor’s initial claim determination might prompt a more successful response. Presuming the patient demographics are entered without error, the insurance information is correct, the patient is eligible for coverage, and all precertifications and authorizations were obtained, check for these other common errors.
Medical Necessity
Denials for “medical necessity” are not always what they seem. Individuals often assume that the physician reported an incorrect diagnosis code. Consider the service/procedure code when trying to formulate a response to the denial. When dealing with procedure codes, it is likely the denial is received for a mismatched diagnosis.
For example, a payor might deny a claim for cardiopulmonary resuscitation (92950) that is associated with a diagnosis code of congestive heart failure (428.0), despite this being the underlying condition that prompted the decline in the patient’s condition. The payor might only accept “cardiac arrest” (427.5) as the diagnosis for cardiopulmonary resuscitation because it was the direct reason for the procedure. After you ensure that the documentation supports the diagnosis, the claim should be resubmitted with the corrected diagnosis code.
If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely that the diagnosis code is the issue. When dealing with Medicare in particular, this type of denial likely is the result of a failure to respond to a prepayment request for documentation. Medicare issues prepayment requests for documentation for the following inpatient CPT codes: 99255, 99254, 99233, 99232, 99223, 99239, and 99292. If the documentation isn’t provided to the Medicare review department within the designated time frame, the claim is automatically denied. The reason for denial is cited as “not deemed a medical necessity.” Some providers misunderstand this remittance remark and assume that the physician assigned an incorrect diagnosis code. Although that might be true, it probably is due to a failure to respond to the prepayment documentation request. Appealing these claims requires the submission of documentation to the Medicare appeals department. Once the supporting documentation is reviewed, reimbursement is granted.
Bundling
The National Correct Coding Initiative (NCCI) identifies edits that ultimately affect claims submission and payment. The Column One/Column Two Correct Coding Edits and the Mutually Exclusive Edits list code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group. Under some well-documented circumstances, the physician is allowed to “unbundle” the services by appending the appropriate modifier.
When services are denied as being “incidental/integral” to another reimbursed service (e.g., bundled), the claim should not automatically be resubmitted with a modifier appended to the “bundled” procedure code.
Documentation should be reviewed to determine if the denied service is separately reportable from the paid service. Only when supported by documentation can the physician append the appropriate modifier and resubmit the claim. For example, a hospitalist evaluated a patient with congestive heart failure and pleural effusions. The hospitalist determined that the patient requires placement of a central venous catheter (36556). Because the patient’s underlying condition was evaluated and resulted in the decision to place a central venous catheter, both the visit (99233) and the procedure (36556) can be reported. If submitted without modifiers, some payors may deny payment for the visit because it was not “integral” to the catheter placement. You should resubmit those claims with modifier 25.
Place of Service
Ensure that the place of service (POS) matches the service/procedure code. For example, say a hospitalist performs a consultation in the ED and determines that the patient does not need to be treated as an inpatient but provides recommendations for ED care and outpatient followup. Avoid a mismatch of the service code and the location. Consults performed in the ED should be reported with outpatient consultation codes (99241-99245) as appropriate. The correct POS should be the ED, not the inpatient hospital. Reporting outpatient codes with an inpatient POS (e.g., 21: inpatient hospital, 31: skilled nursing facility) will result in claim denial.
The same is true when trying to report inpatient consultation codes (99251-99255) in an outpatient location (e.g., 23-ED). The appropriate response for this type of denial is to resubmit the claim with the correct the POS and service/procedure code. A complete list of POS codes and corresponding definitions can be found in Chapter 26, Section 10.5 of the Medicare Claims Processing Manual, available at www.cms.hhs.gov/manuals/downloads/clm104c26.pdf.
Provider Enrollment
Provider enrollment issues occur when a physician’s national provider identifier (NPI) is not properly linked to the group practice. More often than not, the group practice receives claim rejections for enrollment issues when services involve nurse practitioners or physician assistants who have not enrolled with Medicare or cannot enroll with non-Medicare payors.
For example, a nurse practitioner independently provides a subsequent hospital-care service (e.g., 99232). The claim is submitted and Medicare reimburses the service at the correct amount as a primary insurer. The remaining balance is submitted to the secondary insurer. Because the submitted claim identifies the service provider as a nonphysician provider, who likely is not enrolled with the non-Medicare payor, the claim is rejected.
If the physician group has a contractual agreement to recognize nonphysician provider services by reporting them under the collaborating physician’s name, the claim can be resubmitted in the physician’s name. In absence of such an agreement, the claim should be written off. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
Reference
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
In order to recover the appropriate payment for services provided by hospitalists, the following must occur:
- The billing provider renders service fully, or jointly with a resident under the teaching physician guidelines or nonphysician provider under the shared/split billing rules;
- The service is completely and accurately documented in the medical record;
- The correct information is entered on the claim form that is submitted to the payor; and
- The service is determined to be a covered benefit and eligible for payment.
Claims frequently are rejected or denied. Even more frequently, the physician or billing staff does not understand the reason for the denial. The typical reaction to claim denial is twofold: “appeal with paper” and “write off.” In other words, send a copy of the physician notes to the payor and consider the claim unsuccessful and payment unable to be obtained.
Examining and understanding the payor’s initial claim determination might prompt a more successful response. Presuming the patient demographics are entered without error, the insurance information is correct, the patient is eligible for coverage, and all precertifications and authorizations were obtained, check for these other common errors.
Medical Necessity
Denials for “medical necessity” are not always what they seem. Individuals often assume that the physician reported an incorrect diagnosis code. Consider the service/procedure code when trying to formulate a response to the denial. When dealing with procedure codes, it is likely the denial is received for a mismatched diagnosis.
For example, a payor might deny a claim for cardiopulmonary resuscitation (92950) that is associated with a diagnosis code of congestive heart failure (428.0), despite this being the underlying condition that prompted the decline in the patient’s condition. The payor might only accept “cardiac arrest” (427.5) as the diagnosis for cardiopulmonary resuscitation because it was the direct reason for the procedure. After you ensure that the documentation supports the diagnosis, the claim should be resubmitted with the corrected diagnosis code.
If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely that the diagnosis code is the issue. When dealing with Medicare in particular, this type of denial likely is the result of a failure to respond to a prepayment request for documentation. Medicare issues prepayment requests for documentation for the following inpatient CPT codes: 99255, 99254, 99233, 99232, 99223, 99239, and 99292. If the documentation isn’t provided to the Medicare review department within the designated time frame, the claim is automatically denied. The reason for denial is cited as “not deemed a medical necessity.” Some providers misunderstand this remittance remark and assume that the physician assigned an incorrect diagnosis code. Although that might be true, it probably is due to a failure to respond to the prepayment documentation request. Appealing these claims requires the submission of documentation to the Medicare appeals department. Once the supporting documentation is reviewed, reimbursement is granted.
Bundling
The National Correct Coding Initiative (NCCI) identifies edits that ultimately affect claims submission and payment. The Column One/Column Two Correct Coding Edits and the Mutually Exclusive Edits list code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group. Under some well-documented circumstances, the physician is allowed to “unbundle” the services by appending the appropriate modifier.
When services are denied as being “incidental/integral” to another reimbursed service (e.g., bundled), the claim should not automatically be resubmitted with a modifier appended to the “bundled” procedure code.
Documentation should be reviewed to determine if the denied service is separately reportable from the paid service. Only when supported by documentation can the physician append the appropriate modifier and resubmit the claim. For example, a hospitalist evaluated a patient with congestive heart failure and pleural effusions. The hospitalist determined that the patient requires placement of a central venous catheter (36556). Because the patient’s underlying condition was evaluated and resulted in the decision to place a central venous catheter, both the visit (99233) and the procedure (36556) can be reported. If submitted without modifiers, some payors may deny payment for the visit because it was not “integral” to the catheter placement. You should resubmit those claims with modifier 25.
Place of Service
Ensure that the place of service (POS) matches the service/procedure code. For example, say a hospitalist performs a consultation in the ED and determines that the patient does not need to be treated as an inpatient but provides recommendations for ED care and outpatient followup. Avoid a mismatch of the service code and the location. Consults performed in the ED should be reported with outpatient consultation codes (99241-99245) as appropriate. The correct POS should be the ED, not the inpatient hospital. Reporting outpatient codes with an inpatient POS (e.g., 21: inpatient hospital, 31: skilled nursing facility) will result in claim denial.
The same is true when trying to report inpatient consultation codes (99251-99255) in an outpatient location (e.g., 23-ED). The appropriate response for this type of denial is to resubmit the claim with the correct the POS and service/procedure code. A complete list of POS codes and corresponding definitions can be found in Chapter 26, Section 10.5 of the Medicare Claims Processing Manual, available at www.cms.hhs.gov/manuals/downloads/clm104c26.pdf.
Provider Enrollment
Provider enrollment issues occur when a physician’s national provider identifier (NPI) is not properly linked to the group practice. More often than not, the group practice receives claim rejections for enrollment issues when services involve nurse practitioners or physician assistants who have not enrolled with Medicare or cannot enroll with non-Medicare payors.
For example, a nurse practitioner independently provides a subsequent hospital-care service (e.g., 99232). The claim is submitted and Medicare reimburses the service at the correct amount as a primary insurer. The remaining balance is submitted to the secondary insurer. Because the submitted claim identifies the service provider as a nonphysician provider, who likely is not enrolled with the non-Medicare payor, the claim is rejected.
If the physician group has a contractual agreement to recognize nonphysician provider services by reporting them under the collaborating physician’s name, the claim can be resubmitted in the physician’s name. In absence of such an agreement, the claim should be written off. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
Reference
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
In order to recover the appropriate payment for services provided by hospitalists, the following must occur:
- The billing provider renders service fully, or jointly with a resident under the teaching physician guidelines or nonphysician provider under the shared/split billing rules;
- The service is completely and accurately documented in the medical record;
- The correct information is entered on the claim form that is submitted to the payor; and
- The service is determined to be a covered benefit and eligible for payment.
Claims frequently are rejected or denied. Even more frequently, the physician or billing staff does not understand the reason for the denial. The typical reaction to claim denial is twofold: “appeal with paper” and “write off.” In other words, send a copy of the physician notes to the payor and consider the claim unsuccessful and payment unable to be obtained.
Examining and understanding the payor’s initial claim determination might prompt a more successful response. Presuming the patient demographics are entered without error, the insurance information is correct, the patient is eligible for coverage, and all precertifications and authorizations were obtained, check for these other common errors.
Medical Necessity
Denials for “medical necessity” are not always what they seem. Individuals often assume that the physician reported an incorrect diagnosis code. Consider the service/procedure code when trying to formulate a response to the denial. When dealing with procedure codes, it is likely the denial is received for a mismatched diagnosis.
For example, a payor might deny a claim for cardiopulmonary resuscitation (92950) that is associated with a diagnosis code of congestive heart failure (428.0), despite this being the underlying condition that prompted the decline in the patient’s condition. The payor might only accept “cardiac arrest” (427.5) as the diagnosis for cardiopulmonary resuscitation because it was the direct reason for the procedure. After you ensure that the documentation supports the diagnosis, the claim should be resubmitted with the corrected diagnosis code.
If the “medical necessity” denial involves a covered evaluation and management (E/M) visit, it is less likely that the diagnosis code is the issue. When dealing with Medicare in particular, this type of denial likely is the result of a failure to respond to a prepayment request for documentation. Medicare issues prepayment requests for documentation for the following inpatient CPT codes: 99255, 99254, 99233, 99232, 99223, 99239, and 99292. If the documentation isn’t provided to the Medicare review department within the designated time frame, the claim is automatically denied. The reason for denial is cited as “not deemed a medical necessity.” Some providers misunderstand this remittance remark and assume that the physician assigned an incorrect diagnosis code. Although that might be true, it probably is due to a failure to respond to the prepayment documentation request. Appealing these claims requires the submission of documentation to the Medicare appeals department. Once the supporting documentation is reviewed, reimbursement is granted.
Bundling
The National Correct Coding Initiative (NCCI) identifies edits that ultimately affect claims submission and payment. The Column One/Column Two Correct Coding Edits and the Mutually Exclusive Edits list code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group. Under some well-documented circumstances, the physician is allowed to “unbundle” the services by appending the appropriate modifier.
When services are denied as being “incidental/integral” to another reimbursed service (e.g., bundled), the claim should not automatically be resubmitted with a modifier appended to the “bundled” procedure code.
Documentation should be reviewed to determine if the denied service is separately reportable from the paid service. Only when supported by documentation can the physician append the appropriate modifier and resubmit the claim. For example, a hospitalist evaluated a patient with congestive heart failure and pleural effusions. The hospitalist determined that the patient requires placement of a central venous catheter (36556). Because the patient’s underlying condition was evaluated and resulted in the decision to place a central venous catheter, both the visit (99233) and the procedure (36556) can be reported. If submitted without modifiers, some payors may deny payment for the visit because it was not “integral” to the catheter placement. You should resubmit those claims with modifier 25.
Place of Service
Ensure that the place of service (POS) matches the service/procedure code. For example, say a hospitalist performs a consultation in the ED and determines that the patient does not need to be treated as an inpatient but provides recommendations for ED care and outpatient followup. Avoid a mismatch of the service code and the location. Consults performed in the ED should be reported with outpatient consultation codes (99241-99245) as appropriate. The correct POS should be the ED, not the inpatient hospital. Reporting outpatient codes with an inpatient POS (e.g., 21: inpatient hospital, 31: skilled nursing facility) will result in claim denial.
The same is true when trying to report inpatient consultation codes (99251-99255) in an outpatient location (e.g., 23-ED). The appropriate response for this type of denial is to resubmit the claim with the correct the POS and service/procedure code. A complete list of POS codes and corresponding definitions can be found in Chapter 26, Section 10.5 of the Medicare Claims Processing Manual, available at www.cms.hhs.gov/manuals/downloads/clm104c26.pdf.
Provider Enrollment
Provider enrollment issues occur when a physician’s national provider identifier (NPI) is not properly linked to the group practice. More often than not, the group practice receives claim rejections for enrollment issues when services involve nurse practitioners or physician assistants who have not enrolled with Medicare or cannot enroll with non-Medicare payors.
For example, a nurse practitioner independently provides a subsequent hospital-care service (e.g., 99232). The claim is submitted and Medicare reimburses the service at the correct amount as a primary insurer. The remaining balance is submitted to the secondary insurer. Because the submitted claim identifies the service provider as a nonphysician provider, who likely is not enrolled with the non-Medicare payor, the claim is rejected.
If the physician group has a contractual agreement to recognize nonphysician provider services by reporting them under the collaborating physician’s name, the claim can be resubmitted in the physician’s name. In absence of such an agreement, the claim should be written off. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
Reference
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.
Word of Mouth in the Digital Age: Online Physician Ratings
Medical Verdicts
Bleeding mother is transferred, but her baby is stillborn
A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.
PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.
PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.
VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.
Hysterectomy to blame for loss of second ovary?
A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.
PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.
PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.
VERDICT Kansas defense verdict.
To learn more about chronic pelvic pain , read Dr. Fred Howard’s article
Misplaced sutures in hysterectomy lead to death
DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.
PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.
PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.
VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.
Did amniotomy cause cord prolapse and infant’s problems?
A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.
PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.
PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.
VERDICT $500,000 Michigan settlement.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Bleeding mother is transferred, but her baby is stillborn
A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.
PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.
PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.
VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.
Hysterectomy to blame for loss of second ovary?
A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.
PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.
PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.
VERDICT Kansas defense verdict.
To learn more about chronic pelvic pain , read Dr. Fred Howard’s article
Misplaced sutures in hysterectomy lead to death
DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.
PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.
PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.
VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.
Did amniotomy cause cord prolapse and infant’s problems?
A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.
PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.
PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.
VERDICT $500,000 Michigan settlement.
Bleeding mother is transferred, but her baby is stillborn
A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.
PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.
PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.
VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.
Hysterectomy to blame for loss of second ovary?
A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.
PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.
PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.
VERDICT Kansas defense verdict.
To learn more about chronic pelvic pain , read Dr. Fred Howard’s article
Misplaced sutures in hysterectomy lead to death
DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.
PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.
PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.
VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.
Did amniotomy cause cord prolapse and infant’s problems?
A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.
PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.
PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.
VERDICT $500,000 Michigan settlement.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The available information about the cases presented here is sometimes incomplete; pertinent details of a given situation therefore may be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.