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N E W S L E T T E R A u g u s t 2 0 1 6 E d i t i o n

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SOGH Newsletter 8.2016

CODETHIS!”(CaseoftheMonth)ObservationCare:SameDateAdmissionandDischarge

byLori-LynneA.Webb,CPCandReneeAllen,MD,FACOGJuly12,2016CaseExcerpt(summaryandnarrativeofactualcase):A38yoG1P0at32weeks2/7daysisawakenedatapproximately3:30ambypainfuluterinecontractions.ThepatientarrivesattheEDandistransferreddirectlyfromtheEDtotheOBL&Dunit.Thepatientreportspainfuluterinecontractionswhileintriage.Thepatientdoesreporthavingvigorousandslightly“rough”sexualintercoursewithinthelast12hrs.Shereportsgoodfetalmovement,butdeniesdizziness,nausea,lossofconsciousness,tremors,seizures,SOB,chestpain.Thepatientalsodeniesanypreviouscomplicationsduringthecurrentgestation.Herpastmedical,surgicalandsocialhistoryisnegative.Adetailedandcomprehensiveexaminationwasperformedthatentailedthefollowingsignificantresults:PE:VitalSigns:Afebrile,vitalsignsstable.BP:130/80General:Thepatientisawell-developed,well-nourished,femaleinnoacutedistress.Abdomen:Soft.Fundalheightconsistentwith32weeks,singlefetus,vertexSpeculumexam:Cervix1.5cmdilated,noactivebleedingbutfriable,nothinning,nolesions,nopoolingofamnioticfluid.Repeatexamonehourlatershowedcervixwasnow2cmdilated.NST:Fetalheartrate:155bpm,category1andreactive.Testingwasbasedover45minutesonthefetalmonitor.Toco:Uterinecontractionsarepresentaboutevery4-6minutes.Labs/Imaging:�Urinalysis:negativeforproteinuriaorhematuria�BesideOBSonogramperformedbyOBHospitalist:AFIisat16.2cm,andnegativeforplacentapreviaorplacentalhemorrhage;placentaappearsintact.ThepatientwasadmittedtoobservationstatusonL&DwithadiagnosisofPretermContractions.Shewasgivensubcutaneousinjectionsofterbutalineq3h(totalof3)andwasplacedoncontinuousfetalmonitoringwithrepeatedcervicalexaminationsasneeded.Thepatient’scontractionsweremonitoredcloselyandstayedsteadyatabout6-7perhour,afteradministrationoftheterbutaline.Thepatientreportedthatthecontractionsbecamelessintenseovertimeafterthemedicationwasadministeredandsheeventuallydescribedhercontractionsasverymild.Tenhoursafteradmissiontoobservationstatus,thepatient’scontractionsarenotedtohavereducedtoapproximately3perhourandreportedtobenon-painful.Patientisdischargedwithpretermlaborprecautionsandpelvicrestfornext10days.


AstheOBhospitalist,howwouldyourservicesbecoded?ANSWER:

ICD-10DiagnosisCodingconsiderationsinclude:O60.03 Pretermlaborwithoutdelivery,thirdtrimesterO09.513 Supervisionofelderlymultigravida,thirdtrimesterZ3A.32 32weeksgestationofpregnancy EvaluationandManagementCodes(E&M)E&M Item Modifier99234.25-in/outsameday(greaterthan8hrstime)

ObservationAdmissionH&P 25=E&MandProcedure

CPT Item Modifier76815 Utrasound 26=Professional

Component59025 FetalNST

CodingBrief:Theob/gynhospitalistassignedadiagnosisofpre-termlaborwithoutdeliveryforthispatient.UnderICD-10,anypregnancycomplicationdiagnosiscodemustbeaccompaniedbyacodeintheZ3Afamily,specifyinggestationalage.AlsoaspertheICD-l0guidelines,incodingforobstetrics,ifthetrimestersareknown,itistobecoded,inadditiontotheweeksofgestation.InthiscaseZ3A.33denotes32weeksgestation.Thisisthefirstpregnancyforthispatientwhois38yearsandthusisconsideredadvancedmaternalage.Physicianswhoadmitapatienttoobservationcareforaminimumof8hours,butlessthan24hoursandsubsequentlydischargeonthesamecalendardateshallreportanObservationorInpatientCareService(IncludingAdmissionandDischargeServices)CPTcode(99234-99236).InaccordancewiththeCentersforMedicare&MedicaidServicesClaimsProcessingManual,whenreportinganobservationcareadmissionanddischargeserviceCPTcode(99234-99236)themedicalrecordmustinclude:• documentationmeetingtheE/Mrequirementsforhistory,examinationandmedicaldecisionmaking;• documentationstatingthestayforhospitaltreatmentorobservationcarestatusinvolves8hoursbutlessthan24hours;• documentationidentifyingthebillingphysicianwaspresentandpersonallyperformedtheservices;and• documentationidentifyingthattheadmissionanddischargenoteswerewrittenbythebillingphysician •


Lori-LynneA.Webb,CPC,CCS-P,CCP,CHDA,COBGCandICD10CM/PCSAmbassador/TrainerisanE&M,andProcedurebasedCoding,Compliance,DataChargeentryandHIPAAPrivacyspecialist,withover20yearsofexperience.Lori-Lynne’scodingspecialtyisOB/GYNoffice&HospitalistServices,MaternalFetalMedicine,OB/GYNOncology,Urology,andgeneralsurgicalcoding.Shecanbereachedviae-mailatwebbservices.lori@gmail.comoryoucanalsofindcurrentcodinginformationonherblogsite:http://lori-lynnescodingcoachblog.blogspot.com/.Dr.RenéeAllenservedco-authorofthiscolumn.SheistheSOGHLiaisontotheACOGCommitteeonHealthEconomicsandCoding.ShecurrentlyworksasanOB/GYNHospitalistwithMednax/ObstetrixatEastsideMedicalCenterinSnellville,Georgia.


Sim Corner Eclamptic Seizure

Presented by Vanessa Torbenson, MD July 22, 2016 Case Summary:

Length 10-15 minutes

Patient presents with new onset hypertension and headache. During evaluation patient sustains a witnessed seizure with concomitant fetal bradycardia.

Target group: Obstetricians, Midwives, Anesthesia

Possible Team members for the Scenario:

Obstetrician Midwife Anesthesiologist Primary RN

Secondary RN Patient Family Member

General Learning Objectives

Communicate effectively with patient/family

Communicate effectively with team using crisis resource management skills

Scenario Specific Goals:

1. Recognize eclamptic seizure. 2. Create a safe physical environment for the patient. 3. Take appropriate steps to control/minimize effects of seizure and ensure

maternal stability. 4. Demonstrate effective teamwork in a critical situation. 5. Demonstrate knowledge of medications and their doses used to treat patients

with an eclamptic seizure.

Debriefing Overview:

1. Reviewsequenceofevents.


2. Review learning objectives 3. Review communication and team work skills4. Sharekeyassessmentsandlearningpoints

Patient Case Summary:

Carmen is a 19 year old G1 at 37 weeks who is sent to L&D from clinic with new onset elevated BP. Her blood pressure was 162/91 in clinic. On arrival to L&D Carmen begins to complain of a pounding posterior headache as well as seeing spots. The fetal tracing is initially category 1. She then displays seizure activity with rhythmic tonic/clonic movements for about a minute before becoming obtunded and post-ictal.

Additional information:

• Allergies: NKDA • Medications: PNV • Ht 5’6 • Weight 170 lbs • EFW 3.5 kg • PSH neg • VS HR 85; RR 20; BP 180/110;Temp 37.4 • FHT’s Category 1 • GBS pending; RPR Non-reactive; HIV negative; Rubella immune; • 1 hour Glucola: 110 • Soc history; single lives with parents

Set up: Patient in labor bed, IV taped in place in arm (may elect to have no IV as scenarios progress, blood pressure cuff on (high blood pressure (180/100 on a card taped to monitor where BP would normally show). Fetal monitor showing FHR around 140 bpm.

Equipment:

• IV taped to patient • Bed with rail down • BP Cuff and monitor


• FHR tracing showing category 1 strip • Eclampsia kit including Labetalol, hydralazine MgSo4 • Syringes

Sequence of Events:

1. Responder #1 (RN)—Recognize maternal emergency, initiate code button in room, stay with

patient and attempt to make a safe environment 2. Responder #2 (RN)— Aids in initial management, helps get patient into safe position, assesses

airway/breathing, obtains IV access (if not present) 3. Responder #3 (CNM or resident)— Ensures hemodynamic stability of patient, orders magnesium

and appropriate blood pressure treatment, assesses fetus 4. Responder #4 (Anesthesia/OB/Nurse)— Will help ensure adequate ventilation/oxygenation. If

seizure has not abated (it should have by this time), can pharmacologically treat seizure 5. Responders #1-4 — All should work as a team to plan next steps of management (control blood

pressure, obtain magnesium, assess fetus)

• BP180/100• Patientwithtonic/clonic

seizures• FHRtracingwithbradycardia• Bedraildown

• Emergencycalllightactivated

• Bedraillifted• Makeasafeenvironment

formother• Remainswithpatient

• MgSO4initiatedthroughIV/IMifnoIV

• Ensureadequateventilation/oxygenation

• BP’streatedwithLabetalol/hydralazine

• FHRassessed;bradycardiaignoredduringself-limited

• ControlofBP• ContinuedFetalassessment• Useoffurtheranti-seizure

medsifnotcontrolledwithMgSO4

• Planfordelivery


Teaching Points: 1) Immediate goals in eclampsia are to initiate medications to prevent the next seizure, establish patient airway/ventilation/oxygenation, and control blood pressure. This can be accomplished by turning patient to left side, applying a jaw thrust to open their airway, and attempting bag/mask ventilation.

2) If IV access has not been secured, this should be done expediently and a load of 4 -6 g of magnesium sulfate is given over 20 minutes (assuming this has not been done, 2 g should be given over 10 minutes if patient has previously been loaded with magnesium). If there is no IV access, 5 g magnesium should be given IM into each buttock. Severe range blood pressures can be treated with labetalol (10-20 mg) or hydralazine (5-10 mg) IV.

3) Fetal bradycardia can occur during and/or immediately after a seizure, but does not mandate immediate delivery unless it is persistent

4) If seizures have not stopped by the time anesthesia arrives with medications, they may administer benzodiazepines (midazolam) to break the seizure.

Debrief:

• What went well? • What could we have done better? • How did you feel the communication was? • What steps should be taken when we think a patient has eclampsia?

Eclampsia Review:

Eclamptic seizures are usually self-limited. If prolonged, IV midazolam (2mg, may be repeated every few minutes as needed) or IV lorazepam (Ativan, 2 mg, may be repeated every few minutes up to 8 mg) are preferred methods for breaking the seizure. Lorazepam can be given as 4 mg IM if no IV is present.

Magnesium should also be given, 4-6 g IV over 20 minutes preferred, 5 g into each buttock IM, if there is no IV access.


Incidence: Eclamptic seizure occurs in 2 to 3 percent of women with severe features of preeclampsia who are not receiving anti-seizure prophylaxis.

Reference:

•Eclampsia, Errol R Norwitz, MD PHD MBA, et al, Up to date, Jun 28, 2016

Vanessa Torbenson, MD is a consultant in the Division of Obstetrics at the Mayo Clinic and an instructor at the College of Medicine.

QuestionsorfeedbackonSimCorner?Contactusat:[email protected]


PracticeMattersbyGaryPerson,MDMay16,2016AfterbeingapartofalargeOBGYNprivatepracticefor26yearsIretiredat59totropicalbliss.MyhusbandhadtakenafantasticjobopportunityinFloridaandsowedecidedtorelocate.However,daysfilledwithbicyclingandsailingwerenotenoughtosatisfymycravings.Ineededtoheadbacktowork.KnowingthatIdidnotwanttogofullthrottleasIdidwithprivatepractice,beinganob/gynhospitalistsseemedtoofferjusttherightworklifebalanceIwaslookingfor.IwasfortunatetobeofferedapositionasahospitalistwithObHospitalistsGroup(OBHG).Iquicklyacceptedandbecameanob/gynhospitalistwithOBHGatSacredHeartHospitalinPensacola,Florida.SacredHeartHospital,locatedinthenorthwestcornerofthestate,isalargemedicalfacilitywith566beds.AssuchwereceivepatientsfromsurroundingAlabamaandFlorida.Thelabor&delivery(L&D)unithas17beds,3operatingrooms,and7OBemergencydepartment(OBED)beds.Wealsohavea18bedantepartumunit.OurdoctorscomefromgroupandsoloprivatepracticeandalsoincludeUniversityofFlorida(UOF)faculty(4),16residents(4ateachyear),andmaternalfetalmedicinespecialists(3lookingfora4th).TheOBGYNhospitalistsroundoutthisphysicianteamwith3(soontobe4)members.TheUniversityofFloridafacultysupportthehospitalistmodelbycoveringsix24hourshiftseachmonth.Soinessence,weareamixedbunch.Havingsuchalargeinpatientbasetocover,weperforminterdisciplinaryroundstwicedaily.Webeginourshiftat7AMwithroundsinvolvingresidents,nursesUOFfacultyandob/gynhospitalists.WebeginbyreviewingourpatientsonL&D.Wethenmovetoourhighriskobstetricinpatientservice,tobefollowedbyourpostpartumpatients.MFMmakeseparateroundswiththeseniorlevelresidentsandcoordinatehighriskcare.Ourteamalsoparticipatesinthehospitalwidesafetyhuddle,whichoccursat8AMweekdays. Asshiftschangeat7PMroundsarerepeatedwiththesameincomingandoutgoingstaff.Wetrytoencouragerecognitionof“goodcatches,safetyconcerns,andfatigueissues”duringroundstwicedaily.Wefeelroundingtwiceadaycreatesasafetynetforthepatientsandfacilitatesthoroughcommunicationbetweenallteammembers.TheOBEDseesall(andIdomeanall)pregnantpatientafter16weeksofgestationwhopresentseekingurgentoremergencycare.Patientsoftheprivatepracticesmaybeseenbytheob/gynhospitalistsortheirprivateattendings.Theresidentsseealltheirpatientsandanypatientwhopresentswithoutadoctoronstaff.Patientswhodonothavedoctorsonstaffareoftenreferredtoasunattached.TheOBEDprovidessufficientvolumetoallowustoofferaclinicalrotationforthePGY1residents.AllpatientsseenbytheresidentsintheOBEDisseenunderthesupervisionoftheob/gynhospitalists.


DuringtheweektheUniversityofFloridafacultycoverresident’spatientsinL&Dfrom7Ato7PwithOBHGtakingoverthistaskintheeveningsOBHGalsoisresponsibleforandfacilitatecareforunattachedOBGYNconsultswiththemainED.ResidentsseethesepatientsunderthesupervisionoftheOBHGfaculty.Wehaveasurgicaltraumaservicethatisactiveinourcommunity.MostsevereOBtraumaaretakentoourhospitalaswehaveasurgicaltraumaserviceinhouse.Asthehospitalistwearethefirstresponderstoacuteproblemssuchascategory3fetalhearttracingsandmaternalhemorrhage.WearesupportiveofourprivateMDsandofferasecondaryroleintheirpatient’scare.SoloOBGYNdoctorsoftensigntheirservicesovertotheOBHGwhentheyleaveforvacationsorCMEevents.Thesepatientsbecomepartofourteachingserviceandarethereforeseenbytheresidents.JustabouttheonlyarmofthedepartmentthattheObhospitalistsisnotinvolvediswiththegynoncologyservice.As anadded safetynet forourpatientswehavea system that allowsus tohaveabackup physician in place if the Ob hospitalists is not immediately available foremergencies.Afterall,onecannotcareforanectopicinthemainORwhilecoveringanactivelylaboringmultiparaonL&Dsafely,simultaneously.Thebackupfortheob/gynhospitalistisourUniversityofFloridafaculty.OneelementofourcarewhichcanstandtobeimprovedisourEMR.Wehave2hospitalEMRsystemsforpatientcarealongwithaseparateoutpatientEMRsystem.OurinpatientsystemsarePatientKeeperandIngenious,whichcoversmostofthehospital,includingpostpartumcare.ObTraceViewisusedforantepartumandL&Dpatients.Soinessence,myworkdayconsistsoflogginginandoutofthreedifferentEMR,sometimesforthesamepatient.Thisisoneareaofinefficiencywehopetorectifyinthenearfuture.Overall,ourserviceisdynamic,challengingandexhilarating.AttheendofmyshiftIfeelfulfilledthatIhavepositivelyimpactedthecareexperiencedbymostpatientsthathaveenteredourunit.Ourserviceasob/gynhospitalistsisfarreachingintothecareoftheindigent,unattached,privatepractice,residentsandperinatologypatients.Wesupportourprivatephysicians’practices,teachandsupportourresidentsandtheirpatients,giveourtalentedandwelleducatednursingstaffsupportastheyguideourpatientsandkeepthemsafe.Overall,thispositionoffersaverysatisfyingadditiontomynewly“retired”lifestyle.Ilovemyjobandmylife!

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