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, experts say. For example, report V15.41 if a patient comes in for treatment for

post-traumatic stress disorder (PTSD) because of a previous rape. Another appropriate instance for reporting V15.41 is when a patient who was impregnated during a rape incident presents to the ob-gyn either in labor or experiencing problems

related to the pregnancy.

Don't report V15.41 as a primary diagnosis. The primary diagnosis is the presenting problem, and the V code helps to explain more specifically that diagnosis.

3. Put Rape Codes In Correct Order

Report rape 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. You then report the secondary code (in this case, the rape code) to indicate the circumstances

surrounding the diagnosis, she says. The E rape code must also be followed with an E code from the E960-E969 series to indicate the relationship between the victim and attacker.

4. Report Accompanying Injury Codes

Be sure to report all injury codes. 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, experts

say. 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 959.14 (Injury, other and unspecified; trunk; other injury of external genitals).

You can expect a variety of procedures from laceration repair to fracture care when reporting rape-case treatment, such as: 

 - 57420 ��" Colposcopy of the entire vagina, with cervix if present   

- 57452 ��" Colposcopy of the cervix including upper/adjacent vagina.

You may have noticed that in your ob-gyn office, as in many others, standard protocol calls for the collection of evidence using a rape evidence collection kit. Either your 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

Note: You should, out of courtesy, avoid billing the patient for this service.