ED Coding and Reimbursement Alert

Your documentation must satisfy billing requirements and hold up in court if needed.

When ED physicians treat rape and assault victims, you'll need to ensure that the documentation captures the services rendered for all injuries and that it supports assigning the most specific diagnosis codes possible for medical legal reasons and to accurately reflect the ED physician's assessment of the circumstances that led to the examination.

Report All Your Services, Not Just the E/M Code

There is typically an evaluation and management (E/M) component to rape and assault exams reported with an emergency department visit code (99281-99285). But frequently procedures, such as laceration repairs and fracture care, are required as well for injuries sustained during the attack, says Betty Ann Price, BSN, RN, President and CEO of PRCS, INC. in Palmetto, FL .

For instance, a vaginoscopy/colposcopy CPT® code 57420 (Colposcopy of the entire vagina with cervix if present) or anal endoscopy CPT® code 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing) may be indicated to determine injuries and collect forensic evidence. The code choice changes when the examination is performed on a child for suspected sexual abuse or assault. CPT® code 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma) would be reported instead of 57420. For repair of vaginal wounds, CPT® code 57200 (Colporrhaphy, suture of injury of vagina, non-obstetrical) may occasionally be performed in the ED.

Will Your Documentation Hold Up In Court?

Chart documentation must be very detailed to identify what services are medically necessary in addition to the E/M code assigned. And since these cases may end up in court, the accuracy of the documentation must be as complete and specific as possible to withstand scrutiny in a trial setting. In the case of child abuse, the burden of accurate diagnosis and supporting documentation is crucial to either save a child from a horrible situation or to protect an innocent defendant from a false charge, says Price.

An important component of the ED visit for suspected rape is collection of forensic evidence. In these circumstances, the bill may not go to the patient or to their insurance company, but potentially to the law enforcement entity requesting the service. Modifier 32 (Mandated services) might be required for those claims. When collection of the "rape kit" evidence is performed by a SANE (sexual assault nurse examiner) and not performed by the ED provider, this would not be a billable service in the ED setting, she adds.

Careful Diagnosis Coding A Must

ICD-9 provides five codes that deal specifically with rape or sexual assault, says Price, each of which will be appropriate only in specific circumstances:

• 995.53 -- child sexual abuse,
• 995.83 -- adult sexual abuse,
• V15.41 -- personal history of physical abuse (rape),
• V71.5 -- observation following alleged rape or seduction (victim or culprit), and
• E960.1 -- rape.

Price says that the 995.xx codes would be reported in the primary position for any rape or assault examinations when documentation supports sexual assault. But the ED physician will also need to assess the circumstances surrounding the patient's visit so the secondary code may be accurately chosen.

E960.1 is required when injuries that indicate rape are documented and would be reported secondary to the sexual abuse code. Plus, it must be accompanied by a second E-code to indicate the relationship between the victim and the attacker such as E967.3 (Perpetrator of child and adult abuse; by spouse or partner). These E codes are found at the back of the 2012 ICD-9 manual under the heading "Homicide and injury purposely inflicted by other persons", she adds.

She also explains that V71.5 is used for alleged sexual assault cases that do not demonstrate identifiable injuries or other distinct signs or symptoms related to the alleged assault. V15.41 would be used only if there was a prior history of abuse or rape, and would never be used as the primary diagnosis for the current encounter.

Under the ICD-10 translation for 995.53, there are codes for both suspected and confirmed child sexual abuse:

• T74.22XA (Child sexual abuse, confirmed, initial encounter)
• T76.22XA (Child sexual abuse, suspected, initial encounter)

Check Out This Case Study

Price shares this case to help guide your coding:

A 16-year old patient arrives at the ED claiming to have been assaulted and raped by her uncle. The ED physician obtains a detailed history and performs a detailed exam, and determines that x-rays should be taken because of injuries sustained on her face and right wrist. Following x-rays that indicate a broken wrist, the physician provides definitive fracture treatment, and sutures a 1.7 cm simple cut on her lip. A colposcopy of the vagina is performed, revealing a vaginal tear that does not require suturing, but is consistent with sexual assault.

99284-25 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) (significant, separately identifiable E/M service)

57420 (Colposcopy of the vagina including cervix if present)

70140-26 (Radiologic examination, facial bones; less than three views) with written interpretation

73110-26 (Radiologic examination; wrist, complete, minimum of three views) with written interpretation

25650-54 (Closed treatment of ulnar styloid fracture)) suggest adding the 54 modifier if the follow up orthopedic care is not provided in the ED

12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less)

Depending on payer specifics, you might need to append -51 or -59 if the documentation supported that the additional procedure 57420 and 12011 met the requirement including separate injury, different site, or different organ system.

995.53 (Child sexual abuse)

813.43 (Fracture of distal end of ulna [alone], closed)

873.43 (Other open wound of the face; lip, without mention of complication)

878.6 (Open wound of genital organs [external] including traumatic amputation; vagina without mention of complication)

E960.1 (Rape)

E967.7 (Perpetrator of child and adult abuse; by other relative)

ICD-9 codes 995.53 and the two E-codes would be linked to 99284-25, 878.6 is linked to 57420, while 813.43 is linked to the x-rays and fracture care, and 873.43 is linked to the facial laceration repair code.