ED Coding and Reimbursement Alert

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 says. Another appropriate instance for reporting V15.41 is when a patient who was impregnated during a rape incident presents to the ED either in labor or experiencing problems related the pregnancy, she adds.
 
Don't report V15.41 as a primary diagnosis, says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va. The primary diagnosis is the presenting problem, and the V code helps to explain more specifically that diagnosis.
 
3. All rape codes: Report diagnosis codes in order. Once you report the most accurate ICD-9 codes, don't sabotage your claim by haphazardly ordering them.
 
If your physician reports E960.1 for rape, you should report the 995.xx codes as the primary diagnosis for any rape or assault examination, Witt says. You then report the secondary code (in this case, the rape code) to indicate the circumstances surrounding the diagnosis, she says. That E code for rape must also follow with an E code from the E960-E969 series to indicate the relationship between the victim and attacker.
 
4. Accompanying injury codes: Be sure to report all of them. As stated above, you use the E code for rape along with the presenting injury codes. Remember to include every injury sustained by the rape victim in your report to paint a clear picture of what happened, Hall says. Your physician may have to testify in court, which makes these facts become even more relevant. Examples of common injuries include open wounds, such as 883.1 (Open wound of finger[s]; complicated), fractures, 814.01 (Fracture of navicular [scaphoid] of wrist) and contusions, 923.3 (Contusion of finger).

 You can expect a variety of procedures from laceration repair to facture care when reporting rape-case treatment. The following two services sometimes used in rape cases warranted new or revised codes in 2003:

You may have noticed that in your ED, as in many others, standard protocol calls for the collection of evidence using a rape evidence collection kit. Either your emergency physician or a sexual assault nurse examiner (SANE) may conduct the examination.
 
You have no CPT code to report for this work because it is technically a service for the prosecuting attorney, not the patient. Money is sometimes available from the appropriate prosecutor's office to pay for the time and effort this exam requires. The evidence kits can be state-specific because of local laws. A 140-page "Sexual Assault Handbook" is available on the American College of Emergency Physician Web site, www.acep.org.
 
You should, out of courtesy, avoid billing the patient for this service.