Ob-Gyn Coding Alert

Coding for rape or sexual abuse exams is a relatively straightforward process. But selecting the correct diagnosis code can be a greater challenge to the ob/gyn coder. The physicians assessment of the circumstances prompting the exam is crucial, so coders must be diligent when assigning the correct diagnosis code for these services, says Melanie Witt, RN, CPC, MA, an independent coding consultant and ob/gyn coding expert based in Fredericksburg, Va. The physicians notes must specifically state the nature of the case, the extent of the injuries and, if known, the perpetrator of the injuries.

E/M Coding for Rape Exams

In most cases, the rape or sexual abuse exam takes place in the emergency department (ED) and the ED coder reports the appropriate emergency E/M codes (99281-99285), according to Barbara Cobuzzi, MBA, CPC, ChBME, president of Cash Flow Solutions Inc., a medical consulting and billing company based in Lakewood, N.J. Cobuzzi says that if the ob/gyn saw the patient in the ED before the ED physician, he or she can report the emergency E/M codes.

In other instances, the ob/gyn may see the patient in the office or another outpatient setting and will perform an E/M service as part of the rape exam. This would be coded using an E/M code from the 99201-99215 series (office or other outpatient services ...), depending on whether the physician is treating a new or returning patient. The code will depend on the level of history, level of exam and/or level of medical decision-making documented in the chart.

If the patients status requires that the physician take longer than 30 minutes beyond the typical time listed in the E/M code, coders may also assign one of the prolonged physician services codes (99354-99355). Be sure to document the additional time in the chart. This scenario is quite possible when dealing with victims of rape or sexual assault, Cobuzzi says. In many cases the patient may be distraught, in shock or experiencing a great deal of pain. The physician may need to proceed more slowly, providing counseling and reassurance so the patient feels as comfortable as possible. Do not assign a prolonged service code if the physician examined the patient in the ED. ED codes do not have a time component in their definitions.

Rape exams conducted in the office are seldom performed immediately after the assault victims reporting a rape are usually seen in the ED. The exam will take a lot of time sometimes several hours and will involve issues beyond medical concerns (i.e., criminal charges and police involvement).

If more than 50 percent of the visit was spent on counseling, the level of E/M code assigned may be based on time, not key elements, Cobuzzi says. In such a case, coders can usually bill a higher-level E/M code.

Reporting Colposcopy Codes

Witt explains that a colposcopy may be performed along with the E/M service, and would be reported with 57452 (colposcopy [vaginoscopy]; [separate procedure]). Coders may report this separately, but should remember to add modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M service to indicate that the E/M service was separate and significant. Witt adds that when the laboratory does not bill the carrier directly, these charges should be reported by the ob/gyn.

Assault Codes Have Special Guidelines

While only five codes in the ICD-9 manual deal directly with rape or sexual assault (995.53, 995.83, V15.41, V71.5 and E960.1), determining which to report can be problematic. Special guidelines govern the use of each of these five codes. For instance, the ICD-9 manual notes that coders must report additional diagnosis codes to indicate associated injuries, as well as the E codes for rape and perpetrator, when assigning 995.83 (adult sexual abuse) and 995.53 (child sexual abuse), Cobuzzi says. The E codes designate the relationship between the victim and the perpetrator (E967.0-E967.9).

Witt adds that V15.41 (personal history of physical abuse [rape]) is used only if there was a history of abuse or rape, and cannot be used as the primary diagnosis. In addition, she explains that V71.5 (observation following alleged rape or seduction) is used when the physician, after observation and in the absence of injuries or other signs or symptoms, decides that the patient was not a rape victim.

Code E960.1 (rape) is used when the injuries confirm rape, Witt says. However, it cannot be used as a primary diagnosis. Instead, you would need to list the injuries that occurred first, and the E code last on the claim.

Coding Case Study

A 38-year-old distraught female arrives at her ob/gyns office and says her boyfriend has sexually abused her. The patient has been seen at the office before, although this visit is unscheduled. The patient has multiple injuries, including facial abrasions and extensive bruising. The patient also has extensive bruising to the thigh and vulvar area and some vaginal tearing. The physician performs a colposcopy and spends an hour and 15 minutes with the patient.

Coding the exam would be as follows:

99214-25 office or other outpatient visit, established patient

99354 prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour

57452 colposcopy (vaginoscopy); (separate procedure).

To code to the highest level of specificity, match a diagnostic code to every documented injury. The list may be long but it will indicate to the payer both the extent of the patients injuries and the need for the prolonged physician service. Based on the injuries described, diagnostic coding options would include 878.6 (open wound of genital organs [external], including traumatic amputation; vagina, without mention of complication), 920 (contusion of face, scalp, and neck except eye[s]), 921.1 (contusion of eyelids and periocular area), 922.4 (contusion of trunk; genital organs), 922.8 (contusion of trunk; multiple sites of trunk), 924.00 (contusion of lower limb and of other unspecified sites; thigh), 959.09 (injury, other and unspecified, injury of face and neck), 995.83 (adult sexual abuse) and E967.0 (perpetrator of child and adult abuse, by father, stepfather, or boyfriend).

Cobuzzi notes that claims like this are challenging to submit because the HCFA 1500 form has room for only four codes. So, she advises coders not to submit these claims electronically. Also, Cobuzzi says it is important to link the diagnosis codes to the appropriate procedure codes.

There may also be occasions for coders to append modifier -32 (mandated services) to the rape or sexual assault codes if the exams are conducted at the request of a police officer or state or local government agency.