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According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence:

  1. An appropriate code from category T74- (confirmed) or T76- (suspected)
  2. Any accompanying mental health or injury code(s) related to the abuse
  3. An external cause code, where applicable, (X92-Y09) to identify the cause of any physical injuries
  4. A perpetrator code (Y07-) if known

Tips:

  • For cases of confirmed abuse or neglect (T74-), add an external cause code from the assault section (X92-Y09).
  • There are Quality Measures codes (e.g., G8733-G8735) for documenting an Elder Maltreatment Screening which may be reported for payers like Medicare.

Add a Perpetrator Code (Y07-) If Known

For cases of confirmed abuse (T74-), add a perpetrator code (Y07-) if the perpetrator of the abuse is known. Do not report a perpetrator code with a suspected case of abuse (T76-).

What to Code When a Suspected Case of Abuse is Ruled Out

If a suspected case of abuse, neglect, or mistreatment (T76-) is ruled out during an encounter, use a (Z04-) code instead, indicating the suspicion has been ruled out:

Z04.4- Encounter for examination and observation following alleged rape
Z04.7- Encounter for examination and observation following alleged physical abuse

Author: 
Wyn Staheli