Coding Domestic Violence

Coding Domestic Violence

Page 18

Cover Story Coding Is Critical for Health Care’s Response to Domestic Violence

By Lisa James, MA, Bill Rudman, PhD and Peter Sawires, MA

Almost one-third of American women report being a victim of domestic violence at some point in their lives.¹

About one-third of all murdered women are killed by an intimate partner.²

The U.S. Department of Justice estimates that nearly four out of 10 women seeking medical attention in emergency departments for violence-related injury are victims of domestic violence.³

In addition to injuries sustained during violent episodes and the threat of death, physical and psychological abuse are linked to a number of adverse physical health effects including arthritis, chronic neck or back pain, migraine and other frequent headaches, stammering, problems seeing, sexually transmitted infections, chronic pelvic pain, stomach ulcers, spastic colon and other digestive problems.⁴

In fact, when domestic violence is documented and coded accurately, the most common diagnoses accompanying a domestic violence code are related either to a chronic or an acute medical problem.⁵

Abuse is also directly related to adverse mental health effects. Twenty-nine percent of all women who attempt suicide were battered, 37 percent of battered women have symptoms of depression, 46 percent have symptoms of anxiety disorder and 45 percent experience post-traumatic stress disorder.^{6, 7, 8, 9}

These statistics are staggering, and because women often interact with the health care system for routine or emergency care before they turn to law enforcement or other domestic violence services, health care systems are in the unique position to identify abuse and intervene early on.¹⁰

The prevalence of domestic violence and the conditions that are associated with it are truly of epidemic proportions. As a result, oversight agencies and clinical guidelines recommend screening and documentation of domestic violence by providers.^{11, 12} Addition-ally, in 1998, the Coding Clinic specified that when domestic violence is present, it must be coded as the primary diagnosis, regardless of other presenting conditions.¹³

However, only 10 percent of primary care providers even routinely screen for domestic violence, ¹⁴ and analysis of Health Care Utilization Project (HCUP) data show that only seven in 100,000 hospitalized patients overall have a domestic violence code entered in their medical record.¹⁵

Abuse is simply not being documented and coded in most cases. Therefore, even with the evidence of domestic violence’s devastating effects, we are only beginning to understand its true impact. Without accurate documentation and coding, health systems lack the large-scale data, formalized procedures and reimbursement schemes to fully implement and sustain screening guidelines. Documentation and coding of domestic violence can improve our ability to conduct useful large-scale research, and it also positively affects reimbursement for screening, identification, assessment, care and follow-up. Health information management (HIM) professionals play a critical role in ending domestic violence because improved documentation and coding will ultimately improve health services for victims.

What Will Proper Documentation and Coding Accomplish?

Accurate documentation and coding of domestic violence facilitates several critical benefits. In the absence of medical record data that can demonstrate a concrete need to re-spond to abuse, or payment for providers to do so, significant change in the health care response to domestic violence will be difficult if not impossible to achieve.

Proper documentation and coding improve continuity of care by allowing each provider who treats a patient to understand the role the abuse might be playing in the presenting condition and by helping to identify patterns of escalation. It also offers new information about health consequences or associated conditions. Data collected as a result of proper documentation and coding facilitates the promotion of informed clinical guidelines based on evidence.

Documentation and coding of domestic violence is also related to reimbursement. Because victims may need services beyond the treatment of physical injuries, such as risk assessment, counseling, safety planning and referral outside the health care system, proper documentation and coding can facilitate reimbursement to providers for these important additional services. Providers will be more likely to incorporate domestic violence screening and intervention into their practice if they are adequately reimbursed for their time.

Accurate documentation and coding also offers benefits in other settings and on the system wide level. The medical record can provide persuasive evidence in legal proceedings and may decrease the likelihood that pro-viders may be asked to testify by offering evidence to persuade the offender to settle prior to court proceedings. Providers and health care delivery sites can be held accountable for failure to diagnose and respond to abuse, and proper documentation can be a powerful tool to protect providers from potential liability.

Coding data that demonstrate the adverse impact of domestic violence on victims, their de-pendents and the health care system are a vital tool in ongoing policy efforts to promote funding for identification and intervention programs, as well as for research.

Why Don’t Providers and HIM Professionals Document and Code Domestic Violence?

A number of issues discourage providers from documenting domestic violence and HIM professionals from coding it accurately and completely. The most obvious reason for pro-viders not documenting domestic violence is that so few routinely screen for it in the first place. Even when a patient presents with an obvious domestic violence-related injury, they are not always asked about the cause. Providers do not screen for many complicated reasons, from lack of training and tools on the dynamics, prevalence and varied health effects of domestic violence and how to ask about abuse, to lack of incentives and institutional support, personal discomfort and many others.

When providers do screen or patients disclose without solicitation, many providers document incompletely or not at all. Some states have reporting laws that can deter providers from documenting. Many health care institutions lack adequate privacy protections leading some providers to fear that the record may reach the abusive spouse, employer or other potentially harmful party. In cases where an injury from domestic violence is not present, a provider may not be educated to understand how the presenting condition may actually be a result of abuse.

HIM professionals may not code domestic violence accurately or at all for similar reasons. Health care providers must document accurately and completely in order for thorough coding to occur. If domestic violence is not identified or documented adequately, it will not be coded correctly. Many HIM professionals do not know the Coding Clinic guidelines on abuse. Institutional supports that encourage HIM professionals to code domestic violence are also very limited. Only 18 percent of managed care organizations have policies, procedures, materials or guidelines on documenting domestic violence,¹⁶ and very little HIM professional training is offered on domestic violence coding.

One of the most significant deterrents to complete and accurate coding of domestic violence is the current reimbursement structure. In outpatient care, there is no CPT code for domestic violence, so unless individuals substitute other CPT codes for screening and intervention, providers will receive no reimbursement for responding.

For inpatient care, domestic violence codes are generally weighted lower than codes for most other clinical conditions, encouraging HIM professionals to either code the abuse as a secondary diagnosis or not at all, a practice that is in direct contradiction to the Coding Clinic guidelines.

In 1998, the Health Care Financing Administration (HCFA) proposed a new severity-adjusted weight that would increase the reimbursement for domestic violence up to 1.741, higher than most other trauma or abuse injuries. Because domestic violence is at the root of so many of these conditions and is required to be the primary diagnosis when present, this change is clearly warranted. However, the proposal has not been implemented yet.

What Can HIM Professionals Do to Make a Difference in the Lives of Battered Women?

There are three important steps HIM professionals can take to improve the health and safety of victims of domestic violence.

1. Code Appropriately for Domestic Violence

ICD-9 codes related to adult domestic violence that should be utilized as pri- mary diagnostic codes by HIM professionals do exist and are categorized into four major areas:

• Adult Maltreatment and Abuse codes: The Adult Physical Abuse code (995.81) is the primary code that identifies each recorded incidence of domestic violence. Other codes in the 995.8 range add specificity such as physical, sexual etc;
• E-codes: E-codes for family violence indicate when and where the abuse happened, to whom or by whom, and how. However, because E-codes are not re-quired, they appear in fewer than 20 percent of documented cases.¹⁷ This results in very little accurate data about the impact of domestic violence. Therefore, HIM professionals should utilize modifier E-codes wherever possible;
• History Codes and Counseling (V-codes): These important codes give us information about the history of abuse or the need for counseling as a result of domestic violence, and should be used whenever possible. However, a history code cannot be used if the condition is still present. If a provider is treating a current injury, the only way to document a history of domestic violence is a narrative in the chart. V-codes that denote suspicion of domestic violence also exist. These (V-71 category) codes cannot be used in conjunction with other domestic violence-related IDC-9 codes because they denote suspicion only; and
• Injury or Abuse codes: Each medical record must also contain an additional injury or abuse code that records the condition for which hospitalization is necessary. In general, these codes have been used as primary diagnosis codes and represent the abuse or violent act suffered by the victim in each individual episode. Injury or abuse codes could identify any type of injury or abuse.

Coding Clinic guidelines require domestic violence to be listed as the primary code. At the very least, HIM professionals should use domestic violence ICD-9 codes including E and V codes as the first secondary code until the weight of these codes is raised.

Although no CPT code currently exists for domestic violence, the following CPT codes can be used when treating a domestic violence victim to receive reimbursement:

• Complex evaluation and management (99303)
• Team conferences (99374-2)
• Care plan oversight (99374-5)
• Preventive medicine services (99381)
• Preventive medicine.counseling (99401)

When.domestic violence is documented, it needs to be codified with an accompanying ICD-9 code. If domes- tic violence specific ICD-9 codes are not used in combination with the above procedure codes, important information about the frequency of domestic violence will not be captured, nor will we ascertain any information about health problems that are associated with abuse. Additionally, accurate use of ICD-9 codes in conjunction with CPT codes not specific to domestic violence could help document the prevalence and complexity of this problem, and ultimately justify the development a new CPT code.

2. Advocate to Improve Documentation and Coding

In addition to coding domestic violence adequately, HIM professionals can lend a powerful voice to advocating that important issues related to coding are addressed. HIM professionals can use the Coding Clinic guidelines as well as other rationales outlined in this article to convince health care administrators, educators and providers that domestic violence must be documented completely.

Adequate documentation should in-clude: a detailed description of the history of abuse; specifics about the abusive incident; physical examination findings, using a body map and photographs if available; use of the patient’s own words, in quotes, along with factually descriptive language; results of any laboratory and other diagnostic procedures; assessment and documentation of information pertaining to suicide or homicide risk, and potential for serious harm or injury; documentation of any police reports or orders of protection, if available; options discussed and referrals offered; and plans for follow-up and other discharge information. HIM professionals can also use the same information to advocate with health system administrators to support the inclusion of domestic violence information in their own training.

Domestic Violence Related E-Codes
E967.1, E967.3, E967.9	Identifies who committed the act of violence
E960 – E968	Identifies the nature of the abuse
E904.0 &E968.4	Identifies the intent of neglect
E980 – E989	Notes whether the injury was accidentally or purposefully inflicted
In addition to DV-related E-codes, other E-codes identify where an act of violence occurred, for example in a house, apartment, outside, etc. (Please refer to the ICD-9-CM code book 2000 for a copy of those codes).

Domestic Violence V-Codes (history codes)
V15.41	physical abuse and rape
V15.42	emotional abuse
V15.49	other abuse
V61.11	counseling for the victim
V61.12	counseling for the perpetrator

Domestic Violence Related ICD-9-CM Codes
995.80	adult maltreatment
995.81	physically abused person, battered person
995.82	adult emotional/psychological abuse
995.83	adult sexual abuse
995.84	adult neglect (nutritional)
995.85	other adult abuse and neglect (multiple forms of abuse)
Health care providers must use the most specific codes, therefore the less specific 995.80 domestic violence code should not be used.

As mentioned earlier, HCFA proposed a new reimbursement level for domestic violence. HIM professionals should encourage HCFA to act on the 1998 proposal, particularly given the Coding Clinic recommendations that domestic violence be listed as a primary diagnosis. HIM professionals and their facilities should contact HCFA, the American Medical Association (AMA), the American Hospital Association (AHA) and the American Health Information Manage-ment Association (AHIMA) and ask to speak with their Coding Clinic representatives. If the “weight” or reimbursement level of the domestic violence code cannot be increased, the Coding Clinic should in the interim recommend that domestic violence be coded as the first secondary code (not the primary diagnosis), so that providers are not financially penalized for documenting accurately.

3. Advocate for Medical Records Privacy

Policies that promote coding and documentation of domestic violence must go hand-in-hand with efforts to ensure maximal confidentiality of medical records. Insurance companies have discriminated against victims of domestic violence if a history of abuse is discovered. ICD-9 codes are included in employer records, and an employer could discriminate against an employee who is a victim. Most importantly, health information is often sent home in bills or explanations of benefits and patient information is often shared with spouses upon request. If the perpetrator discovers that a victim has disclosed the violence, it could further endanger the victim.

Past U.S. Secretary of Health and Human Services Donna Shalala released new rules on the confidentiality of medical records in December 2000, and current Secretary Thompson made them effective on April 14, 2001. The rules provide many vital protections to battered women including a victim’s right to limit disclosures to her abusive spouse and other parties, allowing victims to request that communications such as explanations of benefits or bills be sent to alternate addresses, and setting limitations on the amounts of information that employers and insurers can obtain without patient consent. However, the Secretary only had authority to cover health plans, health clearinghouses and certain health care providers. Therefore, despite the new regulations, many entities that regularly receive health information, including employers, casualty and property insurance companies, marketing firms and workers compensation carriers, are not required by federal law to protect patient privacy. (A detailed analysis of the regulations’ effects on battered women, as well as recommendations for ensuring privacy, are available online at www.fvpf.org/health).

HIM professionals should encourage their institutions to fully implement the new regulations so that they do not put victims at risk by documenting and coding accurately. They should also encourage their institutions to go above and beyond the regulations where necessary to specifically protect medical records on domestic violence. As individuals, HIM professionals can also write their state and federal legislators, encouraging them to fill the gaps left by the new rule.

By coding domestic violence and advocating for better documentation, coding and records protection, HIM professionals can help to end domestic violence by increasing our understanding of abuse, improving our clinical responses and ensuring that health systems fully respond to the needs of battered women.

For more information, including the Family Violence Prevention Fund’s two related papers “Coding and Documentation of Domes-tic Violence” and “Health Privacy Principles for Protecting Victims of Domestic Violence,” and other materials or assistance, call the National Health Resource Center on Domestic Violence at (888) Rx-ABUSE or visit www .fvpf.org/health.

References

1. 1. The Commonwealth Fund, Health Concerns Across a Women’s Lifespan: The Commonwealth Fund 1998 Survey of Women’s Health, May 1999.
2. 2. Fox, J., Zawitz, M., Homicide Trends in the United States, US Department of Justice, Bureau of Justice Statistics, January, 2001.
3. 3. Rand, M., Violence Related injuries treated in Hospital Emergency Department, US Department of Justice, Bureau of Justice Statistics, August 1997.
4. 4. Coker, A., Smith, P., Bethea, L., King, M., McKeown, R., “Physical Health Consequences of Physical and Psychological Intimate Partner Violence,” Archives of Family Medicine, Vol. 9, 2000.
5. 5. Rudman, W. and Davey, D., “Identifying Domestic Violence within Inpatient Hospital Admissions Using Medical Records,” Women and Health, Vol. 30(4), 4:1-15, 2000.
6. 6. Stark, E. and Flitcraft, A., “Killing the Beast Within: Woman Battering and Female Suicidality,” International Journal of Health Sciences, Vol. 25(1), 1995.
7. 7. Housekamp, B.M. and Foy, D., “The Assessment of Posttraumatic Stress Disorder in Battered Women,” Journal of Interpersonal Violence, Vol. 6(3), 1991.
8. 8. Gelles, R.J. and Harrop, J.W., “Violence, Battering, and Psychological Distress Among Women,” Journal of Interpersonal Violence, Vol. 4(1), 1989.
9. 9. Housekamp and Foy, 1991.
10. 10. Holt, V., Kernic, M., Wolf, M., “Rates & Relative Risk of Hospital Admission Among Women in Violent Intimate Partner Relationships,” American Journal of Public Health, Vol. 90 (9), 2000.
11. 11. Joint Commission on Accreditation of Healthcare Organizations, 1995 Comprehensive Accreditation Manual for Hospitals, Oakbrook Terrace, IL, 1995.
12. 12. Family Violence Prevention Fund, Preventing Domestic Violence: Clinical Guidelines on Routine Screening, San Francisco, October 1999.
13. 13. Coding Clinic for ICD-9 CM (1996) Volume 13, #4, fourth quarter: 38-44.
14. 14. Rodriguez, M., Bauer, H., McLoughlin, E., Grumbach, K., (1999). Screening and Intervention For Intimate Partner Abuse: Practices and Attitudes of Primary Care Physicians. The Journal of the American Medical Association, 282, No. 5, August 4, 1999.
15. 15. Rudman and Davey, 2000.
16. 16. National Health Resource Center on Domestic Violence, National Survey of Managed Care Organizations. Family Violence Prevention Fund, San Francisco, CA. August 1999.
17. 17. Rudman, W., Reyes, C. and Hewitt, C. “Clinical Patters Associated with Intimate Partner Violence,” (Poster Session: American Health Services, Los Angeles, CA. Workshop. National Conference on Health Care and Domestic Violence, San Francisco, CA).

Bill Rudman is an associate professor at the University of Mississippi, and Lisa James and Peter Sawires are with the Family Violence Prevention Fund, a national organization based in San Francisco, CA, that seeks to end domestic violence and aids victims of abuse.