# coding child abuse



## fatielara (Jul 20, 2015)

child's mom had concern the child is being sexually abuse, the doctor did an exam and told me to code the case as 995.53 as child sexual abuse , she said it was suspected it was fine to use 995.53, I disagree and wanted to use
v71.81 for observation and eval. Doc says she was plenty experience with the insurance telling her she is correct in using the 995.53. how does anyone else's office's code their cases in these situations?


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## mitchellde (Jul 20, 2015)

fatielara said:


> child's mom had concern the child is being sexually abuse, the doctor did an exam and told me to code the case as 995.53 as child sexual abuse , she said it was suspected it was fine to use 995.53, I disagree and wanted to use
> v71.81 for observation and eval. Doc says she was plenty experience with the insurance telling her she is correct in using the 995.53. how does anyone else's office's code their cases in these situations?



suspected child abuse is not coded with 995.53, this would be confirmed on exam and needs External cause codes for the perpetrator and nature of abuse.  the V71 codes are for suspected but not found on exam.  so it really comes down to how it was documented.


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## fatielara (Jul 21, 2015)

she did an exam and nothing was found, this is what she responded with,

Although my notes says ?concerning for child sexual abuse?, they need to be billed with the child sexual abuse code which I selected.  Just FYI to you all regarding the language.  I cannot say ?most consistent with? in these cases but it is ok to go ahead and code as child sexual abuse as this was an evaluation for it.  

she wants to code all future cases this way also, even my boss agreed with her but I do not.


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## mitchellde (Jul 21, 2015)

We cannot code concerning for abuse as child sexual abuse.  If the exam found nothing then a V71 code is the correct code.  The V71.5 Observation following alleged rape or seduction, in the category for condition not found is much more accurate for the documentation, it too states the reason for the encounter.  These are patient dx codes and if the patient does not have that condition documented then it cannot be used on the claim.


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## Cynthia Hughes (Jul 23, 2015)

fatielara said:


> she did an exam and nothing was found, this is what she responded with,
> 
> Although my notes says ?concerning for child sexual abuse?, they need to be billed with the child sexual abuse code which I selected.  Just FYI to you all regarding the language.  I cannot say ?most consistent with? in these cases but it is ok to go ahead and code as child sexual abuse as this was an evaluation for it.
> 
> she wants to code all future cases this way also, even my boss agreed with her but I do not.



Under HIPAA, physicians must report diagnosis codes according to the ICD guidelines and Coding Clinic guidance where applicable. Coding Clinic of March-April 1987 discussed the issues of suspected conditions ruled out and should be the guidance used in reporting these encounters. Of particular note are the following instructions.

"Patient's (or parent's) statement of rape or seduction and no findings by the examining physician of hemorrhage, laceration(s), or other physical trauma is classified to V71.5. Rape is not a medical diagnosis but a matter of jurisprudence and is, therefore, qualified by the term "alleged" in the title of V71.5. Code V71.5 includes the collection of any specimens, any advice on prophylaxis against pregnancy or venereal disease, and provision of (or for access to) counseling services. If the alleged rape victim is pregnant and there is no evidence of any pregnancy complications, code V22.2 is assigned as an additional code."

"The alleged rape, seduction, or sexual assault inflicted on a woman, child, or man with findings of hemorrhage, external or internal lacerations, and/or other physical or mental trauma is coded to the condition(s) diagnosed. An additional code for child abuse, 995.5, or adult abuse, 995.81, may be used to describe the impact of the injurious and stressful circumstances inflicted (such as humiliation, fear, confusion, and/or helplessness)."

(The 995.5 code was later expanded to include five digits.)

In ICD-10, guidelines instruct "If the documentation in the medical record states abuse or neglect it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-)." and "If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.42, Encounter for examination and observation following alleged rape or sexual abuse, ruled out, should be used, not a code from T76."

I hope this helps.


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