Patient states she was Raped- Dx?!

anne32

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I have a chart where the patient states her ex- husband tried to force himself on her and she felt penetration. This is only in the HPI. The provider did not mention it in the exam or Treatment. Pt does have chlamydia. Would I code T76.21XA- rape, suspected? Or would I not code it at all since provider says nothing about it. Please help!
 

dgambino

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Unless the documentation supports it somewhere other than the H & P, then I would not pull it. I would go by the final diagnosis codes the physician has in the assessment and plan.
 
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