Reimbursement for Sexual Assault Examinations

Law enforcement agencies can apply for reimbursement of sexual assault exams pursuant to article 56.06(a), Texas Code of Criminal Procedure.

The Crime Victims' Compensation Program will reimburse "reasonable costs" associated with forensic sexual assault examinations of victims of alleged sexual assaults in an amount not to exceed $700.00 in the aggregate. CVC has determined that expenses that comply with the Texas Workers' Compensation Commission medical fee guidelines (guidelines), identified as Current Procedural Terminology (CPT) codes, are considered "reasonable expenses." Therefore, you should require your medical providers (physicians) to submit their bills on a Health Care Financing Administration form (HCFA-1500), which is the national standardized health insurance claim form used by physicians.

Sexual assault examiners and Sexual Assault Nurse Examiners (SANE) may submit their bills to you on their standard billing form with a descriptive itemized statement. Certified healthcare facilities, (such as hospitals) that are accredited by the Joint Commission Accreditation of Health Organizations (JCAHO) or Medicare, and that are licensed by the Texas Department of State health Services, must submit their bills to you on a Uniform Billing form (UB-92).

In order to be considered for reimbursement, each cost associated with the medical services or procedures in a sexual assault exam must be itemized and, for services provided by a physician, must be identified with a five-digit Current Procedural Terminology (CPT) code. The CPT code is a nationally accepted systematic listing which is published by the American Medical Association. CPT coding provides an accurate identification of services and procedures.

Bills submitted with the descriptive itemization of a sexual assault examination without further information or services listed and without individual charges listed for each service will receive reimbursement only for the sexual assault exam and not for any additional medical services.

If under the medical fee guidelines there are no specific CPT codes for the medical services or procedures provided in the sexual assault exam, CVC will accept a Revenue Code, or the CPT code for services or procedures that are comparable to those used in the sexual assault exam. For example:

• The services described under Revenue Code R-450 or R-760 most closely reflect the costs associated with a sexual assault exam in an emergency room setting or hospital treatment room (certified healthcare facility). There are no CPT codes, or comparable CPT codes, for a facility that is not a certified healthcare facility.

• The comparable CPT code that most closely reflects the medical services provided by a physician in a sexual assault exam is 99285.

• A sexual assault examiner or a sexual assault nurse examiner should not use CPT or Revenue codes, but should bill the law enforcement agency his or her usual and customary charge for the forensic sexual assault examination on his or her standard billing form. To be considered for reimbursement, the bill for service must include a descriptive itemized statement of the service provided and must be signed by a physician or a licensed nurse practitioner. The OAG will determine the appropriate CPT or Revenue codes.

The following are guidelines to provide further assistance in completing the application:

1. Complete all sections of the one-page application for reimbursement. The verification section of the application must be signed by an appropriate representative of the law enforcement agency who has knowledge of the facts stated in the verification.
2. Attach all bills associated with the requested sexual assault exam to the application. Expenses other than the actual costs for the sexual assault exam, such as treatment or diagnosis of a victim, are not allowable expenses and will not be reimbursed under this program, but may be compensable under a regular CVC claim. Below is a standard list of costs associated with a sexual assault:

• Examination by a physician or a licensed nurse practitioner (with associated codes such as 99285) up to $195.00.

• Examination by a sexual assault nurse examiner or sexual assault examiner up to $195.00.

• Examination by physician, sexual assault nurse examiner, or sexual assault examiner where a colposcopy is performed. Reimbursement for colposcopy is $233.00 with an associated office visit charge of $26.00. Total reimbursement is $259.00. However, the cost of the colposcopy procedure includes the cost of the examination services of the professional and the OAG will not reimburse for both this procedure and the $195.00 fee.

• Examination by physician, sexual assault nurse examiner, or sexual assault examiner where an anoscopy is performed. Reimbursement for anoscopy is $71.00.

• Examination by physician, sexual assault nurse examiner, or sexual assault examiner where a venipuncture procedure is performed. Reimbursement for a venipuncture procedure is $20.00.

• The OAG will reimburse a law enforcement agency up to a maximum amount of $50.00 for the sexual assault examination kit.

• Facility charge by a certified health care facility billed under Revenue codes, R-760 treatment room and R-450 emergency room. Payment up to a fair and reasonable reimbursement rate, not to exceed $250.00.

• Associated laboratory studies and/or procedures up to $150.00.

• Extensive laboratory procedures that require excess supplies and materials require Documentation of Procedure and will be reimbursed up to a maximum amount of $100.00 for the supplies and materials.

• The charge for handling and/or conveyance of the specimen will be reimbursed up to a maximum amount of $20.00.

• Additional evaluation and management with associated codes such as 99499 up to $106.00 per hour.

• The maximum aggregate amount for which the OAG will reimburse a law enforcement agency for all costs associated with a forensic sexual assault examination of a victim will be $700.00. The OAG will not reimburse for any type of sexual assault examination of a suspected perpetrator. The OAG will not reimburse for the laboratory analysis of victim's clothing, or crime scene materials or objects, including weapons.

The law enforcement agency must complete all sections of the OAG approved Application for Reimbursement. Incomplete applications will not be processed and will be returned to the law enforcement agency noting the reason the application is incomplete. All bills associated with the requested forensic sexual assault examination must be attached to the application, and only those expenses for the actual forensic sexual assault examination will be considered for reimbursement. All bills must be submitted at one time. No other bills submitted to the OAG will be processed after the Application for Reimbursement is received. A completed application is one that:

• has been filled out in its entirety;

• has been signed by the appropriate representative of the law enforcement agency who has knowledge of the facts stated in the application;

• is accompanied by all the relevant bills, and includes the appropriate billing codes or itemization and the individual charges for each service provided; and,

• the cost of the sexual assault exam has been paid by the law enforcement agency.