Alleged sexual assault

mitchellde

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You cannot code alleged, was it investigated by the physician and no evidence found? if so then look under category V71 (which are first-listed only). Otherwise code the symptoms.
 
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There are no symptoms and no exam was done. This is on a child. Do you think it's appropriate to use V71.81? However, Category V71 is Observation and evaluation for suspected conditions not found.
 

mitchellde

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Well that is what we use when a victom states there was sexual assual but the physician finds no evidence of assault, but that is after an examination. So did a parent bring the child in alleging sexual assault? If so why no exam?
 
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Yes, a step-parent brought in the child. The Dr said that exam not performed. Dr. deferred exam as child is going to be getting a SANE Exam at a center for children.
 

mitchellde

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Then there is no way say wheter there was an assault or not, I do not see how a visit can be charged if there was no exam to report.
 

Bhavani

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V71.5

You can use this code, this is nothing but a rape condition, V71.5 can be used in this case.
 

mitchellde

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I do not think it fits if there is no exam, that code says observation and evaluation of a suspected condition NOT found. So it would imply then that there was no evidence of assault not that there had been no exam. So I do not think it should be used.
 
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The CC in this section states the following though

The fact that the patient may be scheduled for continuing observation in the office/clinic setting following discharge does not limit the use of this category.
 
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