Pediatric Coding Alert

Question: What codes should I report for a rape exam for a 10-year-old female patient?

Arizona Subscriber

Answer: You would code any E/M service performed in an outpatient setting for any reason, including a rape exam, using an E/M code from the 99201-99215 series. The level of service depends on the level of history, exam and/or medical decision-making documented in the chart. Most pediatricians would expect to report high-level codes such as 99204-99205 for new patients or 99214-99215 for established patients under these circumstances, but your physician's documentation must support these codes.

If the patient's status is such that the pediatrician takes more than 30 minutes beyond the typical time listed in the appropriate E/M code, you could also bill for prolonged physician services (99354-99357).

If the physician performs a colposcopy (CPT Codes , Anogenital examination with colposcopic magnification in childhood for suspected trauma), bill that separately, but add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service you report to indicate that it was separate and significant. Any laboratory tests performed or billed on behalf of the laboratory can also be reported.

-- The answers to You Be the Coder and Reader Question were provided by Jeffrey Linzer Sr., MD, FAAP, MICP, EMS coordinator for the emergency pediatric group at Children's Healthcare of Atlanta at Egleston.