Rape and Assault Exams Require Attention to Detail
Published on Sat Dec 01, 2001
It's a distressing fact in the life of emergency physicians: They occasionally see and treat victims of rape and assault. Because these cases often include a range of injuries, documentation is of the utmost importance to ensure that the proper procedure codes are assigned. Modifiers are also frequently used to explain to insurers why various combinations of services were medically necessary.
Plus, diagnosis coding may be more complex than with other cases. Not only must the ICD-9 codes justify the procedures provided, but they also need to be clearly linked with relevant and distinct services. Finally, because there may be legal ramifications to the findings, the diagnosis codes must accurately reflect the ED physician's assessment of the circumstances that led to the examination.
Reporting the E/M Service
The foundation of coding rape and assault exams is an emergency services code (99281-99285, emergency department visit). In cases of suspected rape, the physician will in all likelihood have to testify in a court of law regarding the history and complete findings of the visit. A complete physical exam is necessary to determine the existence of other trauma and injuries. Plus the psychological state of the patient often requires even more time than the physical exam.
"It is vital that the emergency physician document the level of service very thoroughly," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, Inc., a medical consulting and billing company based in Lakewood, N.J. Always an important consideration, she says it becomes even more significant when a variety of ED services are provided, often the case in rape exams. "Any minor procedure performed during a rape or assault exam has a small E/M service built into the code, which precludes the physician from reporting both the minimal E/M and the procedure. If the physician has not clearly performed a significant and separately identifiable history and physical exam, and cannot demonstrate medical decision-making, the separate ED code shouldn't be reported."
For instance, a colposcopy is sometimes performed during a rape exam in the ED, and would be reported with 57452* (colposcopy [vaginoscopy]; [separate procedure]). When both the significant E/M and the colposcopy are conducted, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be appended to the ED visit code.
Coding changes when the examination is performed on a child for suspected sexual abuse or assault, notes Melanie Witt, RN, CPC, MA, an independent consultant specializing in coding and documentation, based in Fredericksburg, Va., and former program manager for the department of coding nomenclature at the American College of Obstetrics and Gynecology. "CPT code 99170 (anogenital examination with colposcopic magnification in childhood for suspected [...]
