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 [...]