# sexual abuse coding



## eeisenbeil (Dec 19, 2011)

Code 995.53 - sexual abuse of a child - (perpetrator)...  I cannot find a code for sexual abuse of a child - (victim), or a combined code for sexual abuse of a child - victim and perpetrator. Any help would be appreciated


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## TonyaMichelle (Dec 19, 2011)

Code 995.53 is the Victim,  the E codes E967.0 - E967.9 identifies the perpetrator. You would also use V71.5 (Observation following alleged rape or seduction) This includes the victim and culprit.


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## mitchellde (Dec 19, 2011)

TonyaMichelle said:


> Code 995.53 is the Victim,  the E codes E967.0 - E967.9 identifies the perpetrator. You would also use V71.5 (Observation following alleged rape or seduction) This includes the victim and culprit.



The V71.5 is for an ALLEGED rapeNOT FOUND.  you would not use this code in conjunction with a code for the abuse and the e code.  You would use it when abuse had been suspected but then ruled out.


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## nutter98 (Dec 20, 2011)

mitchellde said:


> The V71.5 is for an ALLEGED rapeNOT FOUND.  you would not use this code in conjunction with a code for the abuse and the e code.  You would use it when abuse had been suspected but then ruled out.



I read V71.5 as alleged NOT ruled out.  A person can go to a doctor 3 days later and allege rape but that doctor may not be able to determine if the patient had consentual sex or was raped.  In this case I would use the V71.5.


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## ajs (Dec 20, 2011)

nutter98 said:


> I read V71.5 as alleged NOT ruled out.  A person can go to a doctor 3 days later and allege rape but that doctor may not be able to determine if the patient had consentual sex or was raped.  In this case I would use the V71.5.



True, although in the "Includes" note under the V71 category it states:

"This category is to be used when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, *but after examination and observation, is found not to exist.*  This category is also for use for administrative and legal observation status."

After I read that I could see where you would not want to use this code if there was still a question as to the validity of the victim's allegations.  This could make it appear that the provider found no evidence to substantiate the claim of rape.


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## Rita B. Conley (Dec 20, 2011)

See the following excerpt...hope it helps answer your question

Observation for suspected abuse and neglect, Coding Clinic, Fourth Quarter 2000 Page: 54 to 55 Effective with discharges: October 1, 2000  

Observation for suspected abuse and neglect 

Code V71.8, Observation for other specified suspected conditions, has been expanded with two new codes. Code V71.81, Abuse and neglect, is to be used to identify cases where a patient is observed for suspected abuse or neglect, and it is ruled out. If the abuse or neglect were confirmed the appropriate code from either subcategory 995.5, Child maltreatment syndrome, or 995.8, Other specified adverse effects not elsewhere classified, would be assigned instead of V71.81. Code V71.89 is used to identify observation for all other suspected conditions.  

As with the other observation codes, these new V codes may only be used as a first listed code. 


V71 Observation for suspected medical 
condition 

V71.8 Observation for other specified 
suspected conditions 

V71.81 Abuse and neglect 

V71.89 Other specified suspected 
 conditions 


Question: 

A 3-year-old child, the youngest of a family of three children, was brought for evaluation for suspected abuse. The child's older sibling had been severely beaten by the stepfather and the caseworker had requested that all the family's children be evaluated for abuse. After evaluation, examination and interviews with the child, it was determined that the 3-year-old had not been abused. What is the appropriate diagnosis code for this child? 

Answer: 

Assign code V71.81, Observation for other specified suspected conditions, abuse and neglect.


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## ajs (Dec 20, 2011)

Rita B. Conley said:


> See the following excerpt...hope it helps answer your question
> 
> Observation for suspected abuse and neglect, Coding Clinic, Fourth Quarter 2000 Page: 54 to 55 Effective with discharges: October 1, 2000
> 
> ...



This is old info...these codes have been expanded to fifth digits.  But still points out that the V71 series is for Suspected Conditions that have been found *not to exist.*


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