Documentation, Coding and Billing

  • Document in patient medical record that IPV screening was completed and patient’s response.
  •  Document relevant history:

    o   Details of abuse as recounted by the patient, using “Patient states…”
    o   Name of abuser, if possible, and relationship to your patient
    o   Include date, time, location of incidents where possible
    o   Names or descriptions of any witnesses to the abuse.
  • Document results of physical examination

    o   Describe injuries, use a body map or photographs (with consent from patient) to supplement written documentation; include nature and location of injuries.
  • Document laboratory and other diagnostic procedures
  • Document results of assessment, intervention and referrals.
    o   Document follow-up arrangements
Billing for Routine IPV Screening
In 2013, the United States Public Services Task Force (USPSTF) announced a “Grade B” recommendation to screen women of childbearing age for intimate partner violence (IPV), and provide or refer all women who screen positive to intervention services.  According to the Institute of Medicine (IOM), screening and counseling for interpersonal and domestic violence are an integral part of a comprehensive preventive women’s health exam.  Under the Affordable Care Act, most health plans will be required to cover IPV screening without cost-sharing such as co-pays and deductibles.
There is no specific ICD-9 code for IPV screening.  Use V72.31 if it is part of routine preventive screening services.  Preventive medicine service CPT codes are defined by age of new (99381-99387) or established (99391-99397) patient.  For example use 99385 for an initial comprehensive preventive evaluation and management of new patient, 18-39 years. CPT codes 99401-99412 are used for counseling provided separately at a different encounter on a different day. For example 99401 is used for ~15 minutes of preventive medicine counseling and/or risk factor reduction intervention. CPT 99401-99412 counseling codes should not be reported for patients with symptoms or established illnesses.  For those patients, the appropriate evaluation and management codes (office visits, consultation) should be reported.  For more information, please see Futures Without Violence coding document,