ED Coding and Reimbursement Alert

Your documentation must satisfy billing requirements and hold up in court if needed. When ED physicians treat rape and assault victims, you'll need to ensure that the documentation captures the services rendered for all injuries and that it supports assigning the most specific diagnosis codes possible for medical legal reasons and to accurately reflect the ED physician's assessment of the circumstances that led to the examination.Report All Your Services, Not Just the E/M Code There is typically an evaluation and management (E/M) component to rape and assault exams reported with an emergency department visit code (99281-99285). But frequently procedures, such as laceration repairs and fracture care, are required as well for injuries sustained during the attack, says Betty Ann Price, BSN, RN, President and CEO of PRCS, INC. in Palmetto, FL . For instance, a vaginoscopy/colposcopy CPT® code 57420 (Colposcopy of the entire vagina with cervix if present) or anal [...]