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Thread: Alleged sexual assault

  1. #1

    Question Alleged sexual assault

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    I have a case where the admit and final dx is alleged sexual assault. Any suggestions?
    Julianne Sheetz, CPC

  2. #2
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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.

  3. #3

    Question

    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.
    Julianne Sheetz, CPC

  4. #4
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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?

  5. #5

    Default

    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.
    Julianne Sheetz, CPC

  6. #6
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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.

  7. #7

    Default V71.5

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

  8. #8
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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.

  9. #9
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    I agree with mitchelle . Without exam, especially situation like this I won't bill

  10. #10

    Default

    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.
    Julianne Sheetz, CPC

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