ED Coding and Reimbursement Alert

 It's a distressing fact in the life of emergency physicians: They occasionally see and treat victims of rape and assault. Because these cases often include a range of injuries, documentation is of the utmost importance to ensure that the proper procedure codes are assigned. Modifiers are also frequently used to explain to insurers why various combinations of services were medically necessary.
 
Plus, diagnosis coding may be more complex than with other cases. Not only must the ICD-9 codes justify the procedures provided, but they also need to be clearly linked with relevant and distinct services. Finally, because there may be legal ramifications to the findings, the diagnosis codes must accurately reflect the ED physician's assessment of the circumstances that led to the examination.

The foundation of coding rape and assault exams is an emergency services code (99281-99285, emergency department visit). In cases of suspected rape, the physician will in all likelihood have to testify in a court of law regarding the history and complete findings of the visit. A complete physical exam is necessary to determine the existence of other trauma and injuries. Plus the psychological state of the patient often requires even more time than the physical exam.
 
"It is vital that the emergency physician document the level of service very thoroughly," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, Inc., a medical consulting and billing company based in Lakewood, N.J. Always an important consideration, she says it becomes even more significant when a variety of ED services are provided, often the case in rape exams. "Any minor procedure performed during a rape or assault exam has a small E/M service built into the code, which precludes the physician from reporting both the minimal E/M and the procedure. If the physician has not clearly performed a significant and separately identifiable history and physical exam, and cannot demonstrate medical decision-making, the separate ED code shouldn't be reported."
 
For instance, a colposcopy is sometimes performed during a rape exam in the ED, and would be reported with 57452* (colposcopy [vaginoscopy]; [separate procedure]). When both the significant E/M and the colposcopy are conducted, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be appended to the ED visit code.
 
Coding changes when the examination is performed on a child for suspected sexual abuse or assault, notes Melanie Witt, RN, CPC, MA, an independent consultant specializing in coding and documentation, based in Fredericksburg, Va., and former program manager for the department of coding nomenclature at the American College of Obstetrics and Gynecology. "CPT code 99170 (anogenital examination with colposcopic magnification in childhood for suspected trauma) would be reported instead of 57452." Again, the E/M service must be a distinctly separate service and would be reported with modifier -25 attached.

Frequently, rape and assault victims suffer other injuries as well lacerations, fractures and contusions are the most common. Treatment of associated wounds would also be separately reportable. For instance, an assault patient may present with a broken arm that the ED physician sets during the visit. Besides the ED and colposcopy code, coders would report the appropriate fracture care code (e.g., 25505, closed treatment of radial shaft fracture; with manipulation). This code would be modified with -54 (surgical care only) to indicate that follow-up orthopedic care is not provided in the ED.
 
ED coders may report any diagnostic services provided (e.g., 73090, radiologic examination; forearm, two views). Modifier -26 (professional component) would be added to the x-ray code because the hospital would bill the technical portion of the service. Coders should note that if manipulation is performed while the bone is being set, the ED physician might order subsequent x-rays to ensure the bone has been repositioned properly. If the physician dictated separate radiologic reports that were responsible for further care and treatment of the fracture, these x-rays may also be reported. When this occurs, modifier -76 (repeat procedure by same physician) would be added to 73090 indicating that circumstances required the second, identical service.
 
When multiple injuries are treated (e.g., a broken bone and laceration), claims for relevant treatment would also be submitted. For instance, coders might report 27500 (closed treatment of femoral shaft fracture, without manipulation) and 12053 (layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm) if the patient presented with a broken leg and lacerations of that length on her face. "In this case, coders would add the -51 modifier (multiple procedures) and expect that the lower paying service would be reimbursed at only 50 percent of the fee schedule," Cobuzzi says.
 
Witt advises coders to bill the most extensive procedure first, and append modifier -51 to all other procedures performed the same day by the same physician.
 
Alternatively, modifier -59 (distinct procedural service) would be used if procedures normally bundled together are performed separately during the ED visit. "For instance, laceration repair codes are organized by body site. The complexity of the repair and the combined lengths of any wound at any one site are factored into the code determination," Cobuzzi explains. If different complexities of repairs are conducted at the same body site, modifier -59 would be used to signal that these were separate procedures. A patient may require simple repair of an eight-centimeter wound on the lower-left arm (e.g., 12004*, simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm), as well as an intermediate repair of a 15-centimeter wound on the upper-left arm (12035, layer closure of wounds of scalp, axillae, trunk and/or extremities excluding hands and feet]; 12.6 to 20.0 cm). Both codes may be reported with -59.
 
Note: Multiple closures on different sites would not require the modifier, because they would not be considered bundled.
 
Finally, modifier -32 (mandated services) might be required in rape or assault cases, Witt says. "This would be added when the exams are being conducted at the request of a police officer or other state or local government agency like social services," she says.

ICD-9 provides five codes that deal specifically with rape or sexual assault, according to Witt, each of which will be appropriate only in specific circumstances:
 

995.53 child sexual abuse
 

995.83 adult sexual abuse
 

V15.41 history of physical abuse (rape)
 

V71.5 observation following alleged rape or seduction
 

E960.1 rape.
   
 
"The 995.xx codes would be reported in the primary position for any rape or assault examinations," she explains. "But the ED physician will also need to assess the circumstances surrounding the patient's claim so the secondary code may be accurately chosen."
 
Code E960.1 is required when injuries that indicate rape are documented, she says, and would be reported in the secondary position. Plus, it must be accompanied by a second E code to indicate the relationship between the victim and the attacker (e.g., E967.3, perpetrator of child and adult abuse; by spouse or partner). These codes are found at the back of the 2002 ICD-9 manual under the heading "Homicide and injury purposely inflicted by other persons."
 
Witt adds that V15.41 would be used only if there were a history of abuse or rape, but would never be used as the primary diagnosis. She also explains that V71.5 is used when the physician, after observation and in the absence of actual injuries or other signs or symptoms, decides that the patient was not a rape victim.
 
Cobuzzi adds that the rape diagnosis codes are usually mapped to the E/M and colposcopy codes. "If other injuries occur and are treated, the diagnosis codes that describe the injuries would be linked to those services." For instance, 813.21 (fracture of radius and ulna; shaft, closed; radius [alone]) might be assigned for a broken forearm.

A 19-year-old patient arrives at the ED claiming to have been assaulted and raped by her uncle. The ED physician obtains a detailed history and performs a detailed exam. He determines that x-rays should be taken because of injuries sustained on her face and right arm. Following x-rays that indicate a broken humerus, he sutures a small, simple cut on her lip. A colposcopy is performed, revealing a vaginal tear.

Procedure Coding:
 

99284-25 emergency department visit (significant, separately identifiable E/M service)
 

24505-54 closed treatment of humeral shaft fracture; with manipulation; with or without skeletal traction (surgical care only)
 

57452-51 colposcopy (vaginoscopy); (separate  procedure) (multiple procedures)
 

12013*-51 simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 (multiple procedures)
 

70140-26 radiologic examination, facial bones; less than three views (professional component)
 

73060-26 radiologic examination; humerus, minimum of two views (professional component).

Diagnosis Coding:
 

995.83 adult sexual abuse
 

E960.1 rape
 

E967.7 perpetrator of child and adult abuse; by other relative
 

812.20 fracture of humerus; shaft or unspecified part, closed; unspecified part of humerus
 

959.9 injury, other and unspecified; unspecified site.

ICD-9 codes 995.83 and the two E codes would be linked to 99284-25 and 57452-51, while 812.20 and 959.9 would be linked to the x-rays, fracture care and laceration repair codes.