KMA Model Health Care Protocol on Abuse, Neglect & Exploitation Child, Spouse/Partner, Adult & Elder

VII. HEALTH INSURANCE & REIMBURSEMENT ISSUES

A. General Information

In any DRG payment system, a case with multiple ICD-9-CM codes can be assigned to several different DRG’s by ranking the most resource intensive code first (i.e., the principle diagnosis). This process, performed by the Medical Record department, assures the physician/facility receives the maximum payment for services rendered. The effect of this process is that cases with code #995.81 can be spread throughout 477 valid DRG’s.

B. Adult Maltreatment Syndrome & Related Cases

Adult Maltreatment Syndrome is assigned code #955.81 in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). When used as the principal diagnosis in the DRG assignment process, the case would fall into either:

DRG #454: Adult Maltreatment Syndrome (psychological/physical abuse): other injury, poisoning and toxic effect diagnosis with complications or comorbidity (age 70+); or

DRG #455: Adult Maltreatment Syndrome (psychological/physical abuse): other injury, poisoning and toxic effect diagnosis without complications or comorbidity (age 18 - 70).

Other related adult maltreatment codes:

DRG # 296: Malnutrition (physical neglect): with complications (age 70+)

DRG # 297: Malnutrition (physical neglect): without complications (age 18 - 70)

C. Sexual Assault Examination

The sexual assault examination required under KRS 216B.400(hospitals with emergency departments) will be paid Crime Victims’ Compensation Board at a rate to be determined by administrative regulation promulgated by the board after consultation with the Sexual Assault Response Team Advisory Committee as defined in KRS 403.707. No charge shall be made to the victim for sexual assault examinations by the hospital, the sexual assault examination facility, the physician, the sexual assault nurse examiner, the victim’s insurance carrier, or the Commonwealth. KRS 216B; 107 KAR 2:010.

To obtain forms or further information contact:

D. Crime Victim Compensation Board

Victims of a criminal act who suffer bodily or psychological injury or death or who have lost earnings or support as a result of a crime may be eligible for benefits including reasonable medical and hospital expenses, funeral expenses, loss of earnings if employed at the time of the crime, and psychological counseling. Benefits are also available for dependants of a deceased victim. Generally, the crime must have been committed in Kentucky; the victim must have cooperated with law enforcement agencies; the victim parent or guardian, or survivor must demonstrate an actual need for assistance and show that the injuries from the crime are causing a serious financial hardship. In most cases, the application for compensation must be filed not later than one year after the crime occurred.

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