ED Coding and Reimbursement Alert

It's a situation no healthcare professional wants to encounter, but the reality is, patients present to the ED saying they've been raped and your staff has to toe the line between medical diagnosis and legal determination without overstepping boundaries of fact.
 
Help your physician and other involved persons by keeping the patient record as objectively coded as possible. Your physician determines the physical status of the patient, nothing more, nothing less, and choosing codes based on evidence can lead to seemingly heartless determinations for the victim or alleged perpetrator. But your job is to report a medical situation and to leave indeterminate circumstances for legal professionals to assess.

Below are the ICD-9 codes that deal specifically with rape or sexual assault and justify a relevant procedure, be it an E/M (99281-99285) or treatment of an injury. Make sure you're familiar with all of your options for accurately describing this case:
   995.53 Child sexual abuse
   995.83 Adult sexual abuse
   V15.41 History of physical abuse
   V71.5 Observation following alleged rape or
 seduction
   E960.1 Rape Follow these four coding guidelines, offered by experts, for diagnosing rape cases in the ED:
 
1. V71.5 versus E960.1: Refer to physical evidence. The most controversial diagnosis choice for rape cases is between alleged rape and rape, and only physical evidence should determine your selection. The "important distinction" between these two diagnostic condition boils down to the difference between observation for rape and medical evidence of rape, says Lois Hall, RHIT, CPC, at the Togus Veteran's Administration in Togus, Maine, and a member of the VHA Coding Council.
 
In other words, look for the absence or presence of physical evidence indicating rape not what the patient did, or didn't, tell the physician when determining which of these two diagnosis codes you should select.
 
Report the E code for rape, in addition to the appropriate injury codes, for cases in which the physician finds physical evidence of rape, Hall says. For cases in which the physician finds no physical signs of injury or rape, you should report the V code for alleged rape, V71.5, she says. Look in the physician's notes for indication of a V71.5 case. You should find a statement such as "No physical signs of injury or rape," but not one along the lines of "The rape did not occur," she adds. In other words, the lack of physical evidence alone requires the "alleged" designation, she says.
 
2. V15.41: Remember, history is history unless it affects the present problem. Reserve the code for history of physical abuse only for situations when it impacts current care, Hall says. For example, report V15.41 if a patient comes in for treatment for post-traumatic stress disorder (PTSD) because of a previous rape, she [...]