I had a patient who delivered the first twin vaginal and then there was a shift change and another provider came in and they were having decelerations and the second twin was taken by csection with a different provider and a np assistant. I found guide lines that state bill 59510 with 59409,51. my question is can I bill 59409 for vaginal with a 59 under the first provider and then bill the 59510 and 59514,as under the other providers. I know I will have to appeal this. and the payer is unicare:
first note:
presented for scheduled induction of labor for di-di TIUP on 3/13. Her induction was started with cervidil, which was removed after 12hrs at 10am on 3/14. Low dose pitocin was started and continued until 2030. At 2215, a Cook balloon was placed and at 0500 on 3/15, pitocin was restarted. The Cook balloon came out around 0900 and her CE was 4/70/-1. AROM was performed at 0925 with clear fluid. Pitocin was titrated per protocol until she reached 20mU/min. Around 1730, she was checked by her RN and found to be 5/90/-1. Just over an hour later following a position change, she reported feeling a lot of pressure and was checked again and found to be unchanged. An IUPC was placed. Contractions were monitored and found to be inadequate so the decision was made to continue to titrate pitocin per protocol until contractions were adequate/up to a maximum of 30mU/min. Around 2130, she was feeling more pressure and repeat exam was 6-7/90/0. She was able to get some sleep overnight. Around 0600, she reported feeling a lot of pressure and was found to be involuntarily bearing down with contractions. She was found to be complete with the fetal vertex at +2 station. She was moved to the O.R. to push. She pushed effectively and delivered the fetal vertex in LOA. The anterior shoulder was delivered automatically by maternal expulsive efforts with the assistance of downward traction. The posterior shoulder was delivered with maternal expulsive efforts and upward traction. The remainder of the fetus delivered spontaneously and was placed on the maternal abdomen. The cord was clamped and cut > 30s (at 7min) following delivery. Cord blood was collected for routine testing. Twin B was confirmed to be vertex on exam and AROM was performed at 0634 with clear fluid. Following AROM, deep variable contractions were noted down to the 60s with contractions; she was repositioned to left lateral, pitocin was halved, and fluid bolus started with improvement in the FHRT and return to baseline 140s. The fetal vertex was noted to be at -3 station. Once Twin B had recovered, at 0701, pitocin was begun to be titrated again as contractions had spaced out. The decision was made to move back to the LDRP and allow the vertex to come down with contractions prior to active pushing. Management transitioned to day shift at this time.
second note:
presented to the birthplace on the evening of 3/13/2022 for induction of labor due to known di-/Di twin pregnancy at 38-2/7 weeks. for details of her induction, please see the separate delivery note (of baby A). Patient had a vaginal delivery of baby A at 0630 on 3/16/2022. After over an hour, patient was taken back to her room for continued monitoring. Her Pitocin, which had been decreased by half after the delivery of twin A, was titrated up again. When she reached 20 milliunits of Pitocin, an IUPC was placed. The patient was examined at the time of IUPC placement and her cervix was swollen and she was 9 cm dilated. By 10:30 am, the contractions were getting further apart and pitocin was on 25 mu's/min. There was a persistent cat II tracing and at that time, I discussed recommendation for c/s with patient and her partner. They were both in agreement. The planned procedure was discussed in great detail. We reviewed the risks, including not limited to: Infection, bleeding, damage to the bowel, bladder, other internal organs, nerves and/or vessels, which could require further surgery. All questions were answered and her consent was obtained.]
Anesthesia was notified and the patient was brought to the operating room with her IV running And epidural in place. Patient was then placed into the dorsal supine position with a leftward tilt. A Foley catheter was placed by nursing. Venodyne boots were placed on bilateral lower extremities. Fetal heart tones were obtained in the 140s. Patient received Ancef 2 g preoperatively, as well as a azithromycin 500 mg. A timeout was performed and everyone in the room was in agreement. Vaginal Betadine prep was performed. At this point, we decided to leave the cord clamp on the umbilical cord of baby A which was still protruding from the vagina. We placed the patient in a frog-leg position so this could be easily accessible after delivery of twin B. The patient was then prepped with ChloraPrep and draped in the normal sterile fashion. She was given TXA prior to skin incision. A Pfannenstiel skin incision was made with a scalpel and carried through to the underlying layer of fascia with a second scalpel. Small bleeders in the subcutaneous fat were cauterized with the Bovie. The fascia was nicked in midline and the incision was extended laterally with the Mayo scissors. The inferior aspect of the fascial incision was then grasped with Cokers and the underlying rectus muscle was dissected up bluntly and sharply. In a similar fashion, attention was turned to the superior aspect of the fascial incision, which was grasped with Coker's, and the underlying rectus muscle was dissected off bluntly and sharply. The rectus muscles were then separated in the midline. The peritoneum was identified and opened bluntly with the operators fingers. The incision was extended superiorly and inferiorly to allow good visualization. The bladder blade was then inserted. The anterior serosal surface of the uterus was very unusual looking, and that it looks like the patient had scar tissue just above the lower uterine segment. The vesicouterine peritoneum was identified and grasped with pickups and entered with Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The lower uterine segment was very thin. Using the C safe device, the lower uterine segment was incised in a transverse fashion with a scalpel. The incision was extended laterally with the operator's fingers. The infant's vertex was identified and brought through to the incision with fundal pressure. There was meconium stained fluid noted at this time. The remainder of the body was delivered atraumatically. Cord was doubly clamped and cut and the infant was handed off to the waiting nurse. Cord blood was obtained. A section of the umbilical cord was doubly clamped and cut in order to obtain cord blood gases. At this point, one of the nurses went below the drapes and used The bandage scissors to excise the end of the umbilical cord that contained the clamp. The placenta was then removed manually. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was identified with T clamps and closed in a running locked fashion with 0 Vicryl. A second layer of the same suture was used for imbrication and hemostasis. During closure of the hysterotomy, the uterus remained boggy, so the patient was given buccal misoprostol. After closure of the uterus, there was still some sponginess at the fundus of the uterus, so she was given Hemabate as well. The right tube and ovary appeared normal. There was a left paratubal cyst that was drained with the Bovie. Otherwise, the left tube and ovary appeared normal. There was some fine adhesions on the posterior aspect of the uterus, as well as some swelling, as well as what appeared to be a Masterson's window; all suspicious for endometriosis.
The pelvis was then irrigated copiously with normal saline and the uterus was returned to the pelvis. The hysterotomy incision was inspected again and found to be hemostatic. Arista was placed over the hysterotomy incision for extra hemostasis. The peritoneum was then identified with 4 Kellys and closed in a running fashion with 2-0 Vicryl. The rectus muscles were inspected and found to be hemostatic. The fascia was reapproximated with 0 Vicryl in a running fashion. Small bleeders in the subcutaneous fat were cauterized with the Bovie. Due to the depth of the subcutaneous fat layer, 3, simple, interrupted stitches were placed for reapproximation using 2-0 plain. The skin was closed with undyed 4-0 Vicryl in a running subcuticular fashion. Steri-Strips were placed, followed by a sterile Mepilex dressing. The patient tolerated the procedure well. All sponge, lap, needle, and instrument counts were correct x2. The baby remained skin to skin with mom during the entire procedure.
At the end of the C-section, the sterile drapes were taken down. The operators gloves were changed and inspection of the perineum and vagina was performed. There was a first-degree vaginal laceration noted, which was repaired in the usual fashion with 3-0 chromic. There was continued oozing noted, so a manual sweep was done of the vagina and the cervix and the lower uterine segment, which resulted in several large clots. These will be weighed and added to the quantitative blood loss.Bleeding was stable after that. The patient and her baby were taken back to the room in stable condition.
first note:
presented for scheduled induction of labor for di-di TIUP on 3/13. Her induction was started with cervidil, which was removed after 12hrs at 10am on 3/14. Low dose pitocin was started and continued until 2030. At 2215, a Cook balloon was placed and at 0500 on 3/15, pitocin was restarted. The Cook balloon came out around 0900 and her CE was 4/70/-1. AROM was performed at 0925 with clear fluid. Pitocin was titrated per protocol until she reached 20mU/min. Around 1730, she was checked by her RN and found to be 5/90/-1. Just over an hour later following a position change, she reported feeling a lot of pressure and was checked again and found to be unchanged. An IUPC was placed. Contractions were monitored and found to be inadequate so the decision was made to continue to titrate pitocin per protocol until contractions were adequate/up to a maximum of 30mU/min. Around 2130, she was feeling more pressure and repeat exam was 6-7/90/0. She was able to get some sleep overnight. Around 0600, she reported feeling a lot of pressure and was found to be involuntarily bearing down with contractions. She was found to be complete with the fetal vertex at +2 station. She was moved to the O.R. to push. She pushed effectively and delivered the fetal vertex in LOA. The anterior shoulder was delivered automatically by maternal expulsive efforts with the assistance of downward traction. The posterior shoulder was delivered with maternal expulsive efforts and upward traction. The remainder of the fetus delivered spontaneously and was placed on the maternal abdomen. The cord was clamped and cut > 30s (at 7min) following delivery. Cord blood was collected for routine testing. Twin B was confirmed to be vertex on exam and AROM was performed at 0634 with clear fluid. Following AROM, deep variable contractions were noted down to the 60s with contractions; she was repositioned to left lateral, pitocin was halved, and fluid bolus started with improvement in the FHRT and return to baseline 140s. The fetal vertex was noted to be at -3 station. Once Twin B had recovered, at 0701, pitocin was begun to be titrated again as contractions had spaced out. The decision was made to move back to the LDRP and allow the vertex to come down with contractions prior to active pushing. Management transitioned to day shift at this time.
second note:
presented to the birthplace on the evening of 3/13/2022 for induction of labor due to known di-/Di twin pregnancy at 38-2/7 weeks. for details of her induction, please see the separate delivery note (of baby A). Patient had a vaginal delivery of baby A at 0630 on 3/16/2022. After over an hour, patient was taken back to her room for continued monitoring. Her Pitocin, which had been decreased by half after the delivery of twin A, was titrated up again. When she reached 20 milliunits of Pitocin, an IUPC was placed. The patient was examined at the time of IUPC placement and her cervix was swollen and she was 9 cm dilated. By 10:30 am, the contractions were getting further apart and pitocin was on 25 mu's/min. There was a persistent cat II tracing and at that time, I discussed recommendation for c/s with patient and her partner. They were both in agreement. The planned procedure was discussed in great detail. We reviewed the risks, including not limited to: Infection, bleeding, damage to the bowel, bladder, other internal organs, nerves and/or vessels, which could require further surgery. All questions were answered and her consent was obtained.]
Anesthesia was notified and the patient was brought to the operating room with her IV running And epidural in place. Patient was then placed into the dorsal supine position with a leftward tilt. A Foley catheter was placed by nursing. Venodyne boots were placed on bilateral lower extremities. Fetal heart tones were obtained in the 140s. Patient received Ancef 2 g preoperatively, as well as a azithromycin 500 mg. A timeout was performed and everyone in the room was in agreement. Vaginal Betadine prep was performed. At this point, we decided to leave the cord clamp on the umbilical cord of baby A which was still protruding from the vagina. We placed the patient in a frog-leg position so this could be easily accessible after delivery of twin B. The patient was then prepped with ChloraPrep and draped in the normal sterile fashion. She was given TXA prior to skin incision. A Pfannenstiel skin incision was made with a scalpel and carried through to the underlying layer of fascia with a second scalpel. Small bleeders in the subcutaneous fat were cauterized with the Bovie. The fascia was nicked in midline and the incision was extended laterally with the Mayo scissors. The inferior aspect of the fascial incision was then grasped with Cokers and the underlying rectus muscle was dissected up bluntly and sharply. In a similar fashion, attention was turned to the superior aspect of the fascial incision, which was grasped with Coker's, and the underlying rectus muscle was dissected off bluntly and sharply. The rectus muscles were then separated in the midline. The peritoneum was identified and opened bluntly with the operators fingers. The incision was extended superiorly and inferiorly to allow good visualization. The bladder blade was then inserted. The anterior serosal surface of the uterus was very unusual looking, and that it looks like the patient had scar tissue just above the lower uterine segment. The vesicouterine peritoneum was identified and grasped with pickups and entered with Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The lower uterine segment was very thin. Using the C safe device, the lower uterine segment was incised in a transverse fashion with a scalpel. The incision was extended laterally with the operator's fingers. The infant's vertex was identified and brought through to the incision with fundal pressure. There was meconium stained fluid noted at this time. The remainder of the body was delivered atraumatically. Cord was doubly clamped and cut and the infant was handed off to the waiting nurse. Cord blood was obtained. A section of the umbilical cord was doubly clamped and cut in order to obtain cord blood gases. At this point, one of the nurses went below the drapes and used The bandage scissors to excise the end of the umbilical cord that contained the clamp. The placenta was then removed manually. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was identified with T clamps and closed in a running locked fashion with 0 Vicryl. A second layer of the same suture was used for imbrication and hemostasis. During closure of the hysterotomy, the uterus remained boggy, so the patient was given buccal misoprostol. After closure of the uterus, there was still some sponginess at the fundus of the uterus, so she was given Hemabate as well. The right tube and ovary appeared normal. There was a left paratubal cyst that was drained with the Bovie. Otherwise, the left tube and ovary appeared normal. There was some fine adhesions on the posterior aspect of the uterus, as well as some swelling, as well as what appeared to be a Masterson's window; all suspicious for endometriosis.
The pelvis was then irrigated copiously with normal saline and the uterus was returned to the pelvis. The hysterotomy incision was inspected again and found to be hemostatic. Arista was placed over the hysterotomy incision for extra hemostasis. The peritoneum was then identified with 4 Kellys and closed in a running fashion with 2-0 Vicryl. The rectus muscles were inspected and found to be hemostatic. The fascia was reapproximated with 0 Vicryl in a running fashion. Small bleeders in the subcutaneous fat were cauterized with the Bovie. Due to the depth of the subcutaneous fat layer, 3, simple, interrupted stitches were placed for reapproximation using 2-0 plain. The skin was closed with undyed 4-0 Vicryl in a running subcuticular fashion. Steri-Strips were placed, followed by a sterile Mepilex dressing. The patient tolerated the procedure well. All sponge, lap, needle, and instrument counts were correct x2. The baby remained skin to skin with mom during the entire procedure.
At the end of the C-section, the sterile drapes were taken down. The operators gloves were changed and inspection of the perineum and vagina was performed. There was a first-degree vaginal laceration noted, which was repaired in the usual fashion with 3-0 chromic. There was continued oozing noted, so a manual sweep was done of the vagina and the cervix and the lower uterine segment, which resulted in several large clots. These will be weighed and added to the quantitative blood loss.Bleeding was stable after that. The patient and her baby were taken back to the room in stable condition.