Primary Care Coding Alert

Question: Would you please advise us on how to code for a rape exam? Arizona Subscriber Answer: The CPT coding is straightforward. However, choosing the correct diagnosis/ICD-9 code is another matter.

Any E/M service performed in an outpatient setting for any reason, including a rape exam, would be coded using an E/M code from the 99201-99215 series. The level of service depends on the level of history, level of exam and/or level of medical decision-making documented in the chart.

If the patient's status is such that it took the physician more than 30 minutes beyond the typical time listed in the E/M code that is to be billed (the patient is distraught, in pain, uncommunicative, etc.), you could also bill for prolonged physician services (99354-99357). If the exam took place in the emergency room of the hospital and the emergency physician did not see the patient first, you can also use one of those codes. However, because they do not have a time component in their definitions, you could not bill for prolonged services in addition to the outpatient visit.

If colposcopy (57452*, Colposcopy [vaginoscopy]; [separate procedure]) was performed, bill that separately, but remember to 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 are also reporting to indicate that it was separate and significant. Any laboratory tests performed or billed on behalf of the laboratory can also be reported.

If the examination was performed on a child for suspected sexual abuse, 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma) would be reported instead. For the ICD coding, you have some choices that depend on the physician's assessment of the situation. Five codes in the ICD-9 manual deal directly with rape or sexual assault:
995.53 Child sexual abuse (reported with codes for the injuries and the E codes for rape and perpetrator) 995.83 Adult sexual abuse (with the same codes added as 995.53) V15.41 Personal history of physical abuse (rape) V71.5 Observation following alleged rape or seduction E960.1 Rape. The first two codes must be reported with codes for the injuries, and the E codes for rape and perpetrator. The third code would only be used if a history exists, but cannot be used as the primary diagnosis. The fourth code is used when the physician, after observation and in the absence of actual injuries or other signs or symptoms, decides that the patient was not a rape victim. The last code is used when the injuries confirm rape, but it also cannot be used as a primary diagnosis. Instead, on the claim, you need to [...]