Alleged rape

kiku3@ptd.net

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I need help with this as I have never coded this situation before: (I am coding from a remote location so this is the information from the woman at the front desk along with the progress note from the Doc for the visit)

Father makes appt. and brings his 14 yr old daughter to gyno, 6 days after "alleged rape", (did not go to ER and our Doc was out of town so that was reason for delay supposedly he told the psr at the desk he went to the police) father claims daughter was a virgin, exam was done, Doc prescribed a (preventative)script for infection, father wants study done to see if there is tissue damage - How is this coded? I am assuming with an E/M level or would it be a first annual because a pap was done? Do I use the V71.5 because there is no notation of any bruising, or abuse but a study will be done so can I say that rape is ruled out and use the V71.5? what happens then if in fact something is found in the study? Oh, notation included that she did have her period, no pregnancy test was done.

Really appreciate any help with this!!
 
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