Primary Care Coding Alert

Coders who work for family practices where rape or sexual abuse exams are performed understand there is a range of both procedure and diagnosis codes that may be reported. Coders must be diligent when assigning the correct diagnosis code for these services because the physicians assessment of the circumstances prompting the exam is crucial, explains 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. Rape or sexual abuse exams represent instances where reporting the CPT code is relatively straightforward, but selecting the correct diagnosis code is another matter altogether.

Using E/M Codes With Colposcopy Codes

In most cases, the exam will take place in the emergency department (ED) and be reported with the appropriate ED evaluation and management (E/M) codes (99281-99285), according to Barbara Cobuzzi, MBA, CPC, ChBME, president of Cash Flow Solutions Inc., a medical consulting and billing company based in Lakewood, N.J. Cobuzzi says that if the emergency physician did not see the patient first, the family practice coder may report these codes.

In other instances, however, a family physician may see the patient in the office or an outpatient setting, and will perform an E/M service as part of the rape exam. This, of course, would be coded using an E/M code from the 99201-99215 series, Cobuzzi says. The level of service will depend on the level of history, level of exam and/or level of medical decision-making documented in the chart.

Cobuzzi notes that, if the patients status requires that the physician take longer than 30 minutes beyond the typical time listed in the E/M code that is to be billed, coders may also assign one of the prolonged physician services codes (99354-99355) if the additional time is documented in the chart. This scenario is quite possible when dealing with victims of rape or sexual assault, she points out. In many cases the patient may be distraught, in shock or experiencing a great deal of pain. It is a traumatic situation and the patient may be uncommunicative. The physician may need to proceed more slowly, providing counseling and reassurance so the patient feels as comfortable as possible.

In addition, rape exams conducted in the office are seldom performed immediately after the assault victims reporting a rape immediately are usually seen in the emergency department. When a longer time period has transpired, the exam will take a lot of time sometimes several hours and will involve issues beyond medical concerns (i.e., criminal charges and police involvement).

Cobuzzi reminds coders that the level of E/M code assigned may be based on [...]