Today we will continue our discussion of
Chapter 19's guidelines. These guidelines
we're looking at today have to do with
adult and child abuse, neglect and other
maltreatment. Some of them do require
external cause codes, which were in
Chapter 20 so we'll continue using both
Chapters 19 and 20 in the ICD-10-CM code
book. The guideline we're looking at is
I.C.19.f Adult and child abuse, neglect
and other maltreatment. There are two
categories in our code book T74 and T76
that have to do with this guideline.
The first, T74, is when adult and child
abuse, neglect and other maltreatment is
"confirmed". The second T76 category has
to do with adult and child abuse, neglect
and other maltreatment "suspected". A big
difference. You will have that T76
code first and then your next code is
going to be your injury code or if it's
a mental health diagnosis, your mental
health diagnosis. But that T74 or T76
is the first code in the code sequence.
If the documentation in the record
states abuse or neglect; it's stated "this
is abuse" or "this is neglect", you're going
to code it as "confirmed" but if the
physician uses the word "suspected", then
we can't code that. We have to be
careful as coders that we do not
interpret narrative
descriptions as abuse. We have to have
the physician stating an absolute
confirmation of abuse before we're going
to be coding it. If you have any
doubts based on the documentation you're
looking at, you need to do a query. For
cases of confirmed abuse or neglect, we
do use an external cause code from the
assault section of Chapter 20. That's X92-Y09.
That's going
to identify the cause of the physical
injuries.
If the abuse is confirmed, we're going to
use a perpetrator code from Y07 and
those perpetrator codes are based on the
relationship between the perpetrator and
the victim. If you go and look at that
category, it's going to say "victim's
father", "victim's mother", "victim's brother"
"other relative", so that's how it builds
the perpetrator code. However, if you are
coding a "suspected" case of abuse, you are
not going to report any external cause
or any perpetrator codes. There are also
codes available if the patient is in the
physician's office, for example, or in the
hospital and you are suspecting it's
abuse, but then while they are in, during
this ecounter or during this admission, it's
ruled out and we know it wasn't abuse,
then we're going to use the Z04.71 code
if it's an adult, ruled out or
or code Z04.72 if it's child abuse, ruled out.
If you're using either of
these Z04 category codes, you will
not be using the T76.
The first code had to do with physical
abuse. Let me go back and just show you. We
are looking at abuse, neglect or
maltreatment and then when you get to
the next guideline it's going to say
"alleged rape or sexual abuse" so it's a
little bit different in this part of the
guideline. It's Z04.71 and Z04.72. When
you get to a rape or sexual abuse, you
get a different 4th and 5th
character so it's Z04.41 for alleged
adult rape or Z04.42 for alleged
child rape. As a reminder, all 50 states
and the District of Columbia and the
territories of the United States have
mandatory reporting laws regarding child
abuse and neglect that require
professionals to report suspected
maltreatment to a Child Protective
Services agency. That's why it's so important
that we code these accurately. Incidents
of documented adult abuse complicating a
pregnancy, whether it's suspected or
confirmed, does not go in the T74 or T76
category codes. It goes back to Chapter
15, which were OB codes where they have
specific codes for adult abuse
complicating pregnancy.
Here's an example in the Emergency
Department. Patient is a 13 year old
female who is a victim of child abuse.
The physician has just stated this is
confirmed. She sustained third-degree
burns to her trunk when boiling liquid
was thrown on her by her father. So we're
going to be coding a confirmed case of
child abuse and we are going to be
coding the perpetrator because it's a
confirmed case of abuse. I have the
pathways there on the right. You see that
the T74 code "confirmed" goes first, then
the burn code . Then you start looking at
your external cause codes. For example, the
assault X98 category is there and the
perpetrator code is the last code. The
sequence of the codes is important so
it's important that you follow your
guidelines that helps us know how we
code these, and the correct sequencing. Here's another
one. Shaken infant syndrome. Two-week-old
infant was brought to the ED by first
responders, found to be unresponsive by
his grandmother. The child's stepbrother
admitted shaking the infant because he
would not stop crying and the step
brother was trying to sleep. A CT scan
revealed the infant has a subdural
hemorrhage so our diagnosis is "shaken
infant syndrome" which is a confirmed
case of abuse. The perpetrator
in this case is the child's stepbrother. So I
have a pathway here. Note please that
there is a specific diagnosis for a
shaken infant syndrome. Then you're going
to code the subdural hemorrhage and the
perpetrator code for the stepbrother.
Now let's look at a case of suspected
child abuse, how your documentation might
read. The patient's a three-year-old boy
known to our practice. His mother brought
him in for evaluation after noticing his
left arm is very bruised and the boy
cries when his arm is touched. With his mother
was out of the room, I asked the child if
someone hurt him and he said yes, but he
would not say anything else. There had
been suspected child abuse cases in this
family over the years for this child's
older siblings. X-rays taken today
revealed the boy has a closed spiral
fracture, non-displaced of his left
radius. We applied a cast and asked that
he be brought back in two weeks to check
his healing. The physician has
documented suspected child abuse so in
this case,this takes us to the T76 code
for "suspected" child maltreatment and we
see that there is an instructional note
with T76 category telling us to use
additional code(s) to identify the injury,
which we have done with the S52 code.
Now, let's look at using those Z codes.
Physician office visit -patient is a 10
year old female brought to the office by
her father. He thought that she was not
acting right . While there were no obvious
signs or symptoms present of any injury,
the child has had numerous injuries in the
past and I was initially suspicious she
was a victim of child abuse. However, the
child denies any assault or abuse and
x-rays were unremarkable for any
injuries. Impression: Examination for
physical abuse of a child, ruled out so
this gives us the Z04.72 code so look
carefully at the pathway. See that
you start with "encounter" which takes you
to" examination" which you then follow the
pathway; abuse, physical, ruled out, child
I've re-quoted the guideline there for
you. Please review these guidelines
carefully. To me, the reporting of child
abuse is one of the most important
things you can do as a professional
coder so it's important that the proper
people are notified and the proper
investigations take place to protect our
most vulnerable citizens and that's our
children. So let me know if you have any
questions. Have a good day.