she did an exam and nothing was found, this is what she responded with,
Although my notes says ?concerning for child sexual abuse?, they need to be billed with the child sexual abuse code which I selected. Just FYI to you all regarding the language. I cannot say ?most consistent with? in these cases but it is ok to go ahead and code as child sexual abuse as this was an evaluation for it.
she wants to code all future cases this way also, even my boss agreed with her but I do not.
Under HIPAA, physicians must report
diagnosis codes according to the ICD guidelines and Coding Clinic guidance where applicable. Coding Clinic of March-April 1987 discussed the issues of suspected conditions ruled out and should be the guidance used in reporting these encounters. Of particular note are the following instructions.
"Patient's (or parent's) statement of rape or seduction and no findings by the examining physician of hemorrhage, laceration(s), or other physical trauma is classified to V71.5. Rape is not a medical diagnosis but a matter of jurisprudence and is, therefore, qualified by the term "alleged" in the title of V71.5. Code V71.5 includes the collection of any specimens, any advice on prophylaxis against pregnancy or venereal disease, and provision of (or for access to) counseling services. If the alleged rape victim is pregnant and there is no evidence of any pregnancy complications, code V22.2 is assigned as an additional code."
"The alleged rape, seduction, or sexual assault inflicted on a woman, child, or man with findings of hemorrhage, external or internal lacerations, and/or other physical or mental trauma is coded to the condition(s) diagnosed. An additional code for child abuse, 995.5, or adult abuse, 995.81, may be used to describe the impact of the injurious and stressful circumstances inflicted (such as humiliation, fear, confusion, and/or helplessness)."
(The 995.5 code was later expanded to include five digits.)
In ICD-10, guidelines instruct "If the documentation in the medical record states abuse or neglect it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-)." and "If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.42, Encounter for examination and observation following alleged rape or sexual abuse, ruled out, should be used, not a code from T76."
I hope this helps.