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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 time, not key elements, if more than 50 percent of the visit with the patient was spent on counseling.

Note: Coders would not assign a prolonged service code if the family physician examined the patient in the ED. ED codes do not have a time component in their definitions and, therefore, coders may not bill for prolonged services in addition to the emergency room visit.

Witt explains that a colposcopy may be performed along with the E/M service, and would be reported with 57452 (colposcopy [vaginoscopy]; [separate procedure]). Coders may report this separately, but should remember to add a modifier -25 to the E/M service to indicate that the E/M service was separate and significant. Witt adds that any laboratory tests performed or billed on behalf of the laboratory can also be reported.

Coders should also be aware of one caveat, Witt says. If the examination were being performed on a child for suspected sexual abuse, 99170 (anogenital examination with colposcopic magnification in childhood for suspected trauma) would be reported instead of 57452.

Distinct Situations Define Use of Diagnosis Codes

While only five codes in the ICD-9 manual deal directly with rape or sexual assault, determining which to report can be problematic. A coder will need to rely upon the physicians assessment of the situation when deciding which diagnosis code to assign, Witt says. She adds that special guidelines govern the use of each of these five codes:

995.53 child sexual abuse;
995.83 adult sexual abuse;
V15.41 personal history of physical abuse (rape);
V71.5 observation following alleged rape or seduction; and
E960.1 rape.

For instance, the ICD-9 manual notes that coders must report additional diagnosis codes to indicate associated injuries, as well as the E codes for rape and perpetrator, when assigning 995.83 and 995.53, Cobuzzi says. The E codes that designate the relationship between the victim and the perpetrator (E967.0-E967.9) are found in the back of the ICD-9 manual and are based on the relationship between the victim and perpetrator (e.g., E967.0, perpetrator of child and adult abuse, by father, stepfather, or boyfriend).

Witt adds that V15.41 would be used only if there were a history of abuse or rape. However, it cannot be used as the primary diagnosis. In addition, she explains that V71.5 is used when the physician, after observation and in the absence of injuries or other signs or symptoms, decides that the patient was not a rape victim.

The last code, E960.1, is used when the injuries confirm rape, Witt says. However, it cannot be used as a primary diagnosis. Instead, you would need to list the injuries that occurred first, and the E code last on the claim.

Case Study: A 38-year-old distraught female arrives at her family physicians office and says she has been sexually abused by her boyfriend. The patient has been seen at the office before, although this visit is unscheduled. The patient exhibits multiple injuries, including facial abrasions and extensive bruising. The physician spends an hour and 15 minutes with the patient, and performs a colposcopy.

Coding the exam would be as follows:

99214-25 office or other outpatient visit, established patient; modified to indicate that the E/M service was separate and significant;

99354 prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour;

57452 colposcopy (vaginoscopy); (separate procedure);

995.83 adult sexual abuse;

920 contusion of face, scalp, and neck, except eye(s);

921.1 contusion of eyelids and periocular area;

922.8 contusion of trunk; multiple sites of trunk;

959.09 injury, other and unspecified, injury of face and neck; and

E967.0 perpetrator of child and adult abuse, by father, stepfather, or boyfriend.

Cobuzzi notes that claims like this are challenging to submit because the HCFA 1500 form has room for only four codes. For this reason, she advises coders not to submit these claims electronically. In addition, Cobuzzi says that it is important to link the diagnosis codes to the appropriate procedure codes.

There may also be occasions for coders to append rape or sexual assault codes with modifier -32 (mandated services) if the exams are being conducted at the request of a police officer or other state or local government agency.