Cracking the Code
Sequencing Rules for Child, Adult Abuse
When coding adult and child abuse, neglect, and other maltreatment, it is important to understand the proper sequencing of the diagnoses. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, it is appropriate to assign a diagnosis from subcategory T74, adult and child abuse, neglect, and other maltreatment, confirmed or T76, adult and child abuse, neglect, and other maltreatment, suspected as the primary diagnosis. All other mental health or injury codes should be sequenced as secondary diagnoses. Be sure that the documentation clearly states whether the abuse was confirmed or suspected. For confirmed cases, it is appropriate to report an external cause code from the assault section (X92-Y09) and a perpetrator code (Y07) when the perpetrator of abuse is known. This guidance ONLY applies to confirmed cases.
Q: A 15-year-old patient arrives to the emergency department with complaints of physical assault. The patient is accompanied by their grandmother who confirms that the patient’s boyfriend was the perpetrator. The physician confirms this information to be true and provides treatment to the patient.
A: T74.12XA, child physical abuse, confirmed, initial encounter; Y04.2XXA, assault by strike against or bumped into by another person, initial encounter; and Y07.03, male partner, perpetrator of maltreatment and neglect
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.19.f.