Found 1245 Results Sorted by Case Date
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Florida – Family Medicine – Discontinuation Of Aspirin And Propafenone For A Patient With Arrhythmia After Repair For A Tibial Fracture



On 9/1/2012, a patient suffered a tibial fracture in her left leg after falling during a seizure.  In the aftermath of the fracture, the patient underwent left comminuted tibial open reduction internal fixation (“ORIF”) surgery.

During the patient’s discharge, she was prescribed aspirin and propafenone (Rythmol).  The aspirin was intended to help prevent post-surgical pulmonary embolism.  The propafenone was intended to control the patient’s atrial fibrillation.

On 9/14/2012, the patient was transferred to a rehabilitation facility for post-surgical rehabilitation.

Throughout her post-surgical rehabilitation, the patient was at an increased risk of pulmonary embolism.

Initially, the patient was continued on aspirin and propafenone at the rehabilitation center.

On 9/28/2012, the physician’s orders for October 2012 included a stop order on the administration of the patient’s aspirin and propafenone, effective 10/13/2012 and 10/14/2012.

In late September and early October 2012, a family practitioner electronically signed, approved, and executed the aforementioned physician’s orders.

On 10/18/2012, the patient suffered shortness of breath and decreased oxygen saturation.  Although the family practitioner transferred the patient for treatment at an emergency room, the patient passed away several hours later.

According to the medical examiner, the cause of the patient’s death was pulmonary embolism.

The Medical Board of Florida judged the family practitioners conduct to be below the minimal standard of competence given that he should have facilitated the long-term continuation of aspirin and/or propafenone to the patient.  Also, the family practitioner should not have signed, approved, and/or otherwise have executed physician’s orders that were in conflict with the physician’s intended course of prescribing/treatment for the patient.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $1,708.35 and not to exceed $3,798.35.  The Medical Board of Florida also ordered that the family practitioner complete five hours of continuing medical education in “risk management.”

State: Florida


Date: February 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Shortness of Breath


Diagnosis: Cardiac Arrhythmia, Pulmonary Embolism


Medical Error: Accidental Medication Error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Internal Medicine – Rectal Cancer With Metastatic Disease, Fall, And A Perineal Wound



In July 2013, a patient was diagnosed with rectal cancer with metastasis to the liver.  He was treated with chemotherapy.  His course was complicated by colovesical fistula and scrotal abscess.

On 2/4/2014, the patient underwent a laparoscopic diverting colostomy.  He had further chemotherapy after this operation.

On 7/7/2014, the patient went to Internist A’s office.  At that time, the patient’s medication regimen included a fentanyl patch, hydrocodone-acetaminophen, hydromorphone, valium, zolpidem, and oxycodone-acetaminophen.  Adderall was not listed as a prescribed medication in the patient’s medical records.

On 7/22/2014, the patient was admitted to the medical center after a fall at home.  The accompanying diagnosis included syncope, dehydration, volume depletion, generalized weakness, and perineal wound.  During that hospital stay, the patient was found to have streptococcal bacteremia, for which he was treated with intravenous antibiotics.  In the emergency department’s record from the medical center, Adderall was listed in his prior to admission medication list.  It was continued in the inpatient setting and carried over with his discharge orders at the time of transfer to a skilled nursing facility. Internist A did not perform a medication reconciliation when the patient’s care was transitioned.

On 8/2/2014, the patient was discharged from the hospital.  At that time, his medication regimen was as follows:  Adderall 20 mg daily; zolpidem 10 mg at bedtime; fentanyl patch 25 mcg every 72 hours; oxycodone 10-20 mg every 4 hours as needed; and diazepam 5 mg daily as needed.  Based on the patient’s wife’s concern, the physician covering for Internist A discontinued the Adderall and the fentanyl patch.  However, the discharge summary makes no mention of discharge medications.  The patient was transitioned to a skilled nursing facility for continuation of intravenous antibiotics.  He received physical therapy/occupational therapy there and intravenous antibiotics.  He subsequently developed a fever.

On 9/18/2014, the patient was transferred back to the emergency department for tachycardia and was admitted to the hospital.

On 9/25/2014, the patient was discharged home with his spouse under hospice care.  On 10/1/2014, the patient expired at home.

While at the skilled nursing facility, the patient’s wife was concerned that the patient was on too many medications, that he was not required to ambulate, and that is dentures were lost, which impaired his oral intake.  During this period of time, the patient’s wife made multiple phone calls to Internist A, attempting to express her concerns about the care provided to her husband, but was unable to speak to Internist A.  Internist A failed to communicate with the wife regarding her husband’s condition.

The Board felt that Internist A had practiced below the standard of care given failure to perform medication reconciliation at transitions of care.  He failed to fulfill his responsibility as a treating clinician to update the patient’s wife.  He failed to maintain accurate and adequate medical records.  The patient’s perineal wound was not mentioned in his admissions notes or in subsequent follow-up notes.

The Board issued a reprimand against Internist A.  He was ordered to comply with attending a course in medical record keeping.

State: California


Date: February 2017


Specialty: Internal Medicine, Hospitalist


Symptom: Weakness/Fatigue, Fever


Diagnosis: Sepsis, Colon Cancer


Medical Error: Failure of communication with patient or patient relations, Improper medication management, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Gynecology – Hypoxia During Hysteroscopic Resection



On 1/9/2015, a female presented to a gynecologist for a hysteroscopy to resect a large submucosal fibroid, which was in excess of 3 cm, after being treated in the office for several months.  The Board noted that the gynecologist recommended a complete hysterectomy for the patient, but the patient refused.  Regardless, the gynecologist chose to proceed with a hysteroscopic resection.  Because the fibroid was large, the operative time was far in excess of what would be expected.  During the operation, hysteroscopic fluid management indicated a significant excess in fluid intake.  The excess fluid retention caused the patient to suffer oxygen desaturation as a result of significant pulmonary and laryngeal edema.

The Board expressed concern that the gynecologist failed to stage the operation to avoid prolonged operative time and fluid overload.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: February 2017


Specialty: Gynecology


Symptom: Mass (Breast Mass, Lump, etc.)


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Urology – Treatments Options For Renal Mass In An Elderly Man With History Of Bladder And Renal Cancer



Sometime around 2000, a 77-year-old male presented to a urologist for treatment of hematuria and benign prostatic hyperplasia.  Between 2000 and 2008, the patient continued to receive treatment from the urologist for various medical problems, which included but was not limited to, a right radical nephrectomy for cancer in 2001, a history of bladder cancer recurrence requiring transurethral resection and instillation of BCG (immune therapy) into the bladder, approximately twenty-five cystoscopies, and high grade prostate cancer treated with radiation and androgen deprivation in 2008.

On 12/18/2009, the then 86-year-old patient presented to the urologist with complaints of gross hematuria with clots for one week.  At that time, the urologist ordered a CT scan of the patient’s abdomen and pelvis.

On 12/22/2009, the urologist underwent a CT scan, which revealed a 5.7 cm mass in the upper pole cortex consistent with renal cell carcinoma.

On 12/29/2009, the urologist saw the patient for a follow-up visit.  Having reviewed the CT scan results, the urologist considered various options for treatment, including watchful waiting versus nephrectomy versus nephrectomy/cystectomy.  The urologist did not consider a partial nephrectomy.

On 1/6/2010, the urologist performed an uneventful total left nephrectomy, total cystoprostatectomy, and urinary diversion.  The pathology report showed a 6 cm clear cell cancer of the left kidney, nuclear grade 4/4, and the renal vein and renal sinus were not involved.  The bladder showed papillary transitional cell high-grade multifocal carcinoma in situ.  No tumor invasion was present in the bladder wall.

On 1/9/2010, the patient had developed some hypertension and was noted to have some greenish discharge from his surgical wound.  The patient was returned to surgery for an emergent laparotomy performed by the urologist and a co-surgeon.  During the laparotomy, it was discovered that the patient had small bowel perforations secondary to extensive bowel ischemia.  During the surgery, a bowel resection, jejunostomy, and double barrel colostomy were performed.  At the conclusion of the procedure, the patient had a cardiac arrest and died.

The Board expressed concern that the urologist practiced at a level below the standard of care by not considering less aggressive options such as a partial nephrectomy in a very elderly man with comorbidities.

The Board issued a reprimand and ordered continuing medical education of 40 hours.  It was also recommended that the urologist enrolls in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Urology


Symptom: Mass (Breast Mass, Lump, etc.), Urinary Problems


Diagnosis: Post-operative/Operative Complication, Cancer


Medical Error: Improper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Gastroenterology – Second Colonoscopy Performed Within Days Of First Due To Concerns Of Suboptimal Bowel Preparation



On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding.  On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making.  The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.

On 1/9/2010, the patient underwent a gastroscopy.  Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized.  Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin.  The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.

On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy.  Small oozing angiodysplasias were found in the duodenum and were cauterized.  Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Left-Sided Colitis And Improper Billing



Sometime in May 2009, a patient presented to a gastroenterologist with a history of sporadic rectal bleeding and chronic reflux-type complaints.  An index colonoscopy conducted on 5/7/2009 demonstrated predominantly left-sided colitis. The patient was treated with oral and topical mesalamine preparations.  Initially, the patient’s symptoms responded to the treatment, but then worsened several months later.

On 8/24/2009, the patient underwent a second colonoscopy.  The patient was prescribed oral budesonide to treat what was believed to be an extension of the colitis.  The patient continued to have ongoing symptoms. On 11/9/2009, the patient underwent a third colonoscopy, which showed reduced activity of disease.  On 1/8/2010, the patient underwent a gastroscopy and a fourth colonoscopy in order to determine the course of future treatment. The colitis was believed to be inactive, and the patient was continued on oral mesalamine preparations.  The patient’s increased bleeding was believed to be hemorrhoidal in origin, and internal hemorrhoids were cauterized. The biopsy from the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The patient had difficulty swallowing (dysphagia) and abdominal pain.  The patient underwent gastroscope on 2/15/2010, 3/25/2010, 5/20/2010, and 4/19/2011.  In each instance, biopsies from the gastric antrum and distal esophagus/gastroesophageal junction were obtained, and mild chronic inflammatory changes were observed.  In each instance, the gastroenterologist did not obtain biopsies from the esophageal body. Repeated esophageal dilutions were performed in order to alleviate dysphasia symptoms.  The gastroenterologist did not document the presence or absence of constricting pathology.

The patient underwent additional colonoscopies on 8/24/2010, 4/11/2011, and 12/7/2012.  The patient underwent additional gastroscopies on 12/30/2011, 4/3/2012, 9/21/2012, 1/11/2013, and 3/1/2013.  In each instance, biopsies form the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The gastroenterologist maintained handwritten notes of each visit.  Some of the handwritten notes were not legible. The gastroenterologist consistently failed to note any assessment and/or plan based on the assessment.  The gastroenterologist consistently billed using CPT billing code 99213, in the absence of documenting any expanded problem focused history or medical examination or medical decision-making.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated colonoscopies and gastroscopies of the patient without medical indication or necessity, failed to maintain adequate and accurate medical records of his care and treatment of the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99213, which was not supported by the physician documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Bleeding, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Repeated Colonoscopies And Gastroscopies For Worsening Esophagitis And Billing For Complex Evaluation



On 4/21/2010, a 58-year-old was admitted to the hospital with chest and abdominal pain, nausea, vomiting, and leukocytosis.  The patient was seen by a gastroenterologist for GI consultation.

On 4/29/2010, the patient underwent a gastroscopy, which revealed erosive esophagitis, Los Angeles grade B, and “small ulcers with overlying semi fresh blood” were cauterized.

On 5/21/2010, the patient was re-hospitalized with complaints of persistent abdominal pain.  On 5/28/2010, a second gastroscopy was performed. The ulcers that were previously found had resolved.  The gastroenterologist biopsied the gastric antrum. The reasons for doing so were not documented in the patient’s medical chart.  The patient continued to experience pain, but the medical records did not characterize the pain complaints.

On 6/2/2010, the patient underwent a colonoscopy.  It was unclear from the medical documentation whether the colonoscopy was performed on an urgent basis.  During the study, the gastroenterologist removed small, benign polyps. The gastroenterologist recommended a repeat colonoscopy due to suboptimal bowel preparation.

On 6/15/2010, the patient was hospitalized with complaints of nausea and vomiting.  On 6/19/2010, a third gastroscopy was performed and revealed mild esophagitis. Sometime in August 2010, the patient was hospitalized with complaints of abdominal pain, nausea, and vomiting.  On 8/11/2010, a fourth gastroscopy was performed, which the gastroenterologist interpreted as showing “extensive ulcerative esophagitis with multi foci of blood.”

On 5/24/2011, the patient underwent a fifth gastroscopy, which the gastroenterologist interpreted as showing esophagitis and numerous erosions or superficial ulceration in the lower stomach.  Also on this date, the patient underwent a second colonoscopy, and the gastroenterologist recommended a “follow-up colonoscopy after a more thorough prep.”

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated gastroscopic examinations of the patient without medical indication or necessity, failed to maintain adequate or accurate records regarding his care and treatment of the patient, and submitted billing for each hospital visit with the patient using CPT billing code 99233, or a complex evaluation, which was not supported by the gastroenterologist’s documentation of the visits.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Chest Pain, Nausea Or Vomiting, Abdominal Pain


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Hemorrhoids Cauterized During Multiple Colonoscopies



A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease.  On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain.  The study was interpreted to show mild colitis, but biopsies were normal.

On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms.  The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.

On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers.  The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.

On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy.  The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized.  The colonoscopy was technically inadequate due to retained blood and debris.

On 3/20/2010, the patient underwent a third colonoscopy.  The gastroenterologist interpreted a finding of sigmoid diverticulosis.  On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools.  The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation.  The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.

On 6/5/2010, the patient underwent a fourth gastroscopy.  The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.”  On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding.  The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Multiple Endoscopic Studies For Ulcerative Esophagitis



A patient had been seen by a gastroenterologist, as an outpatient, since sometime in 2005 for chronic gastroesophageal reflux disease (GERD).  The patient had received long-term treatment with acid-reducing medications and prokinetic agents. Between 2005 and 2009, the patient underwent 23 separate endoscopic studies.  The gastroenterologist’s hand-written documentation of his care and treatment of the patient was scant, illegible, and failed to state the gastroenterologist’s thoughts regarding evaluating and/or modifying the patient’s clinical course.

Sometime in June 2010 and again in July 2010, the patient was admitted to the hospital with upper GI tract bleeding.  On 7/13/210, the gastroenterologist dictated an admission summary, which failed to provide any meaningful historical details regarding the patient.  The gastroenterologist used PT billing code 99223 indicating a “complex” level of assessment for the consultation.

From 6/16/2010 through 10/9/2010, the gastroenterologist performed a total of 7 endoscopic studies to evaluate the patient.  The studies demonstrated that the patient had severe ulcerative esophagitis, secondary to reflux and/or vomiting. The gastroenterologist documented that he cauterized areas of hemorrhagic mucosa in the esophagus.  However, the gastroenterologist’s dictated procedure reports failed to document any additional anatomy or physiology related to these studies and treatment.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he failed to properly manage the patient’s reflux disease, performed an excessive number of endoscopic procedures that provided no relief to the patient’s symptoms or improvement in clinical outcome, failed to maintain adequate or accurate records of his care and treatment of the patient, and submitted billing using the CPT billing code 99223, which as not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Bleeding, Nausea Or Vomiting


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Improper treatment, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



California – Gastroenterology – Endoscopic Studies Upon Multiple Hospital Admissions And Improper Billing



Sometime in September 2009, an 86-year-old was evaluated by a gastroenterologist for complaints of abdominal pain, nausea, vomiting, and borderline anemia.  On 9/28/2009, the patient underwent a gastroscopy and was diagnosed with mild esophagitis and angiodysplasias of the lower stomach. The angiodysplasias were cauterized, and the patient was treated with acid-reducing agents and iron replacement.

Sometime in February 2010, the patient was admitted to the hospital on several occasions with urinary tract infection, suspected sepsis, deep vein thrombosis, and complaints of abdominal pain.  The patient underwent a series of endoscopic studies, including gastroscopies on 2/5/2010 and 2/26/2010 and a colonoscopy on 2/26/2010. Abdominal/pelvic CT scans showed an area of segmental small bowel narrowing.

On 3/11/2010, following a barium study, the patient was diagnosed with terminal ileal disease.  On 3/22/2010, the patient underwent a gastroscopy, which the gastroenterologist documented as being a small bowel enteroscopy.  On 4/19/2010, the patient underwent a “colonoscopy with ileoscopy.” The gastroenterologist billed for this examination using CPT billing code 45378.  On 6/16/2010 and 7/3/2010, the patient underwent a gastroscopy with the gastroenterologist. On 7/6/2010, the patient underwent a “colonoscopy with ileoscopy.”  The gastroenterologist billed for this examination using CPT billing codes 45380 and 44380, indicating that he performed both a colonoscopy and an ileoscopy separately instead of billing code 45378, indicating that he performed a colonoscopy with ileoscopy.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed an excessive number of endoscopic procedures on the patient, had inadequate and illegible documentation, and submitted inaccurate billing.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California


Date: February 2017


Specialty: Gastroenterology


Symptom: Abdominal Pain, Nausea Or Vomiting, Urinary Problems


Diagnosis: Gastrointestinal Disease


Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



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