# Alleged sexual assault



## JulesofColorado (Jun 29, 2009)

I have a case where the admit and final dx is alleged sexual assault. Any suggestions?


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## mitchellde (Jun 29, 2009)

You cannot code alleged, was it investigated by the physician and no evidence found?  if so then look under category V71 (which are first-listed only).  Otherwise code the symptoms.


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## JulesofColorado (Jun 29, 2009)

There are no symptoms and no exam was done. This is on a child. Do you think it's appropriate to use V71.81? However, Category V71 is Observation and evaluation for suspected conditions not found.


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## mitchellde (Jun 29, 2009)

Well that is what we use when a victom states there was sexual assual but the physician finds no evidence of assault, but that is after an examination.  So did a parent bring the child in alleging sexual assault?  If so why no exam?


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## JulesofColorado (Jun 29, 2009)

Yes, a step-parent brought in the child. The Dr said that exam not performed. Dr. deferred exam as child is going to be getting a SANE Exam at a center for children.


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## mitchellde (Jun 29, 2009)

Then there is no way say wheter there was an assault or not, I do not see how  a visit can be charged if there was no exam to report.


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## Bhavani (Jun 29, 2009)

*V71.5*

You can use this code, this is nothing but a rape condition, V71.5 can be used in this case.


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## mitchellde (Jun 30, 2009)

I do not think it fits if there is no exam, that code says observation and evaluation of a suspected condition NOT found.  So it would imply then that there was no evidence of assault not that there had been no exam.  So I do not think it should be used.


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## kumeena (Jun 30, 2009)

I agree with mitchelle . Without exam, especially situation like this I won't bill


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## JulesofColorado (Jun 30, 2009)

The CC in this section states the following though

The fact that the patient may be scheduled for continuing observation in the office/clinic setting following discharge does not limit the use of this category.


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## tscarberry (Jun 24, 2013)

*for an er visit you can use v715*

v715 is correct for an alleged rape


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