Ob-Gyn Coding Alert

Careful: How you order your codes makes a big difference It's a situation no healthcare professional wants to encounter, but the reality is, patients present to your ob-gyn saying they have been raped and as a coder, you have to toe the line between medical diagnosis and legal determination without overstepping factual boundaries. Heighten your sensitivity: Help your physician and other involved persons by coding the patient record as objectively 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. Check These Diagnoses Below are the ICD-9 and E codes that deal specifically with rape or sexual assault and justify a relevant procedure, be it an E/M (99201-99215) or treatment of an injury. According to Jeffrey Linzer Sr., MD, MICP, FAAP, FACEP, you need to 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: 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 conditions boils down to the difference between observation for rape and medical evidence of rape. 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. 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, says Christie Thomas, CPC, PCS, coder at Mercy Physicians Group in Fort Scott, Kansas. Look in the ob-gyn'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. Here's the Case for 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, [...]