Replacement Assistant at Delivery

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: Shannon DeConda, NAMAS Moderator

Post Reply
Posts: 44
Joined: Sat Dec 20, 2014 9:32 pm

Thu Feb 07, 2019 1:43 pm

Hello! Thank you in advance for any help you can give us on this unusual scenario.

During the course of a recent C-section Delivery (after failed trial of labor), an assistant was used who also is a MD but not with our practice. Prior to the end of the procedure, she was called to another delivery. One of our midwives scrubbed in to assist with the remainder of the delivery. Based on the following note, is this billable for the our assistant (the Midwife?

DESCRIPTION OF OPERATION: The patient was taken to the operating room where a spinal anesthetic was given. She was placed in a supine position and prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made through a previous incision and carried sharply down to the fascia. The fascia was incised in the midline and bluntly and sharply dissected laterally. The fascia was dissected away from the underlying rectus muscles, which were divided in the midline and the peritoneum entered sharply. The peritoneal incision was extended cranially and caudally with sharp dissection. A bladder flap was developed and the lower uterine segment entered transversely. The incision was extended laterally with sharp dissection. The infant was delivered from a cephalic presentation with fundal pressure and vacuum. The cord was doubly clamped and divided and the infant passed to the waiting pediatric team. The placenta was delivered with uterine massage. The uterine cavity was wiped clean. The uterine incision was closed with a running and locking 0 Vicryl suture. There was one bleeding point in the right incision angle which was made hemostatic with figure-of-eight 0 Vicryl suture. The fallopian tubes and ovaries were noted to be normal. The uterus was returned to the abdominal cavity. The incision was again inspected and noted to be hemostatic. The peritoneum was closed with a running 2-0 Vicryl suture. The sponge and needle counts had been correct. The subfascial space was made hemostatic. The fascia was closed with a running 0 Vicryl suture. The subcutaneous space was irrigated and made hemostatic. The skin was closed with a subcuticular 4-0 Vicryl suture. A sterile dressing was applied and the patient was taken to the recovery room in good condition with an estimated blood loss of 800 mL. There were no complications.
Note: Following closure of uterus, Dr. _____. scrubbed out of case to attend a delivery. CNM ____ immediately scrubbed in to assist for the remainder of the procedure.

Dr. __________

Thank you again,

Post Reply