3 Miss. Code. R. 1-06-601 - Application

1. All bills submitted for payment should be accompanied by a copy of the State of Mississippi Crime Laboratory Sexual Assault Examination Form, and include a standard UB-04 form or other official itemized billing form. NOTE: For minor victims receiving a sexual assault medical forensic examination seventy-two hours or longer after the sexual assault, the authorized non-acute sexual assault exam form for minors >72 hours should be submitted.

2. Payment may be made whether or not the victim pursues prosecution. Though it is strongly encouraged that the victim reports the sexual assault to law enforcement, reporting the assault is the victim's decision. This does not apply to state mandated reporting requirements for minors, vulnerable adults, and certain violent crimes.

3. A request for payment for the sexual assault medical forensic examination must include the International Classification of Diseases (ICD-9) code V71.5 for examination of the victim of sexual assault, code E960.1 for a victim of rape, code V71.81 when there are no forensic findings for a sexual assault exam, code 995.53 when there are forensic findings for a sexual assault exam of a child, or code 995.83 when there are forensic findings for a sexual assault exam of an adult.

4. A request for payment for the sexual assault medical forensic examination must include the following information as applicable:

a. Physician/ARNP, Office or other outpatient services (CPT codes 99201-99205 for New Patient, CPT codes 99211-99215 for Established Patient, CPT codes 99241-99245 for office consultations); Emergency Department Services (CPT codes 99281-99285 for New or Established Patient) which include the collection of evidence as needed in the sexual assault kit.

b. Venipuncture for the collection of whole blood samples (CPT codes 36400, 36405, 36406, 36410, 36415).

c. Laboratory test for pregnancy (CPT codes 84702, 84703, 81025).

d. HIV Testing (CPT codes 86701-86703, 86687-86689) if medically necessary.

e. Hepatitis Panel (CPT codes 80074, 86705, 86709, 87340, 86803) if medically necessary.

f. RPR (CPT codes 86592, 86593) if medically necessary.

g. Herpes Simplex (CPT codes 86694, 86696) if medically necessary.

h. Gonorrhea culture (CPT codes 87040, 87070, 87081, 87590, 87591, 87592) if medically necessary.

i. Chlamydia culture (CPT codes 87320, 86631, 86632, 87110) if medically necessary.

j. Urinalysis (CPT codes 81000-81003, 81005, 81007, 81015) if medically necessary.

k. Urine culture (CPT codes 87086, 87088) if medically necessary.

l. Trichomonas vaginalis (CPT codes 87660, 87205, 87210) if medically necessary.

m. Other laboratory tests if medically necessary.

n. Colposcopy (CPT codes 57420, 57452, 99170).

o. Camera/Other photography (CPT code 99199). Use of this code requires additional reporting information to verify that a camera/photography was used.

p. Medication for prevention of STDs, Hepatitis B, pregnancy, and a three-day supply of HIV prophylaxis.

5. If the victim refuses to have all or portions of the sexual assault exam completed, notes to verify this should be included in the exam form. Payment will be considered for a "partial exam" when allowable exam expenses are incurred, such as medication treatment for prevention of STDs, Hepatitis B, pregnancy, and a three-day supply of HIV prophylaxis.

6. Follow-up sexual assault medical forensic exams/related labs will be considered for payment when the victim is a minor; however, this expense will only be reimbursed the difference between the amount already paid out for the exam (and any other allowable expense) and the maximum payment amount ($1,000) allowed. If the prior payment(s) totals $1,000 then these additional expenses will not be eligible for payment.

7. Expenses for procedures other than those listed above must be justified and submitted, in writing, as being necessary and directly related to the medical forensic examination.

8. Payments for admissions, treatment of injuries, medications such as anti-depressants, sedatives or tranquilizers are NOT ELIGIBLE under this policy. See § 602 (6).

Notes

3 Miss. Code. R. 1-06-601