Health Information Management

Q&A: Are poison control agencies covered entities?

HIM Connection, September 27, 2011

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Q: Should I report ICD-9-CM code V71.5 (observation following alleged rape or seduction) after an alleged assault or rape? The physician did not document any injuries. Code V71.5 falls under the general heading of “observation and evaluation for suspected conditions not found.” The note included with this code category states that it should be used when patients “without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist. This category is also for use for administrative and legal observation status.”

A: You have correctly cited the instructional notation found in the Tabular List of ICD-9-CM for section V71. The section of the note stating “is found not to exist” indicates that is the patient has no sign of injury or disease—not that the event didn’t occur.
 
Consider the following excerpt from Coding Clinic, Second Quarter 2002, p. 58:
Codes from the V71.0–V71.9 series are to be assigned as principal or first-listed diagnoses for encounters or admissions to evaluate the patient’s condition when there is some evidence to suggest the existence of an abnormal condition or following an accident or other incident that ordinarily results in a health problem, and where no supporting evidence for the suspected condition is found and no treatment is currently required. 

Editor’s note: Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children’s Hospital at Stanford in Palo Alto, CA, answered the previous question., answered this question in the September issue of Briefings on Coding Compliance Strategies.



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