Coding and Reporting Adult and Child Abuse, Neglect or Maltreatment

Let's look at the different types of abuse, neglect or maltreatment of children and adults and how to properly assign the principal diagnosis (PDX) on these cases. HIA is seeing that the sequencing of the PDX is incorrect on a number of these reviewed cases. The coders are typically reporting the injury code as the PDX when the ICD-10-CM Index instructs the coder to report the injury as an additional code. This instruction within ICD-10-CM would mean that the “T” code for the adult or child abuse, neglect or maltreatment would be sequenced first.

There are many different types of abuse, but we will be looking at the types that may lead to hospitalization or medical visits. Let’s look at some of the different types of abuse:

Adult Abuse, Neglect or Maltreatment

• Physical abuse—intentional bodily injury
• Sexual abuse—sexual act or behavior that is forced upon a woman, man, or child
• Psychological and emotional abuse—involves threats of violence to scare, control and isolate. This can be bullying, insulting, manipulation, and humiliation.

Occurrences of Abuse (only the ones reported)

• One study shows an average of 24 people per minute are victims of abuse (rape/physical or stalking)
• One study shows an average of 600,000 children are abused in the U.S. each year (about 6 per minute)

With the numbers above, coders are seeing patient records that are victims of abuse in the emergency room, physician offices, or hospitalizations. Let’s look at how to code certain scenarios when patients present for treatment.

Scenarios

• Female patient presents with multiple injuries and is admitted as an inpatient. The H&P states that the patient has a history of physical assaults by her boyfriend. She was found to have a fracture of the three right ribs in addition to multiple contusions over the flank, back and legs. The patient is discharged with a final diagnosis of: Fracture of three right ribs due to intimate partner violence. In this case, the appropriate PDX is T74.11XA (Adult physical abuse, confirmed, initial encounter) and not the fracture of the ribs. The rib fracture would be coded and reported as a secondary diagnosis. The records that have been found during reviews have had the actual injury as the PDX and the coder response is that is the condition treated. That may be the case, but we have guidance from the OCG that must be followed. Per the OCG C.19.f for FY2023 pgs. 82-83, “Sequence first the appropriate code from categories T74.-, Adult and child abuse, neglect, and other maltreatment, confirmed, or T76.-, Adult and child abuse, neglect, and other maltreatment, suspected, for abuse, neglect, and other maltreatment, followed by any accompanying mental health or injury code(s). If the documentation in the medical record states abuse or neglect, it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-).” The coder will also see in the ICD-10-CM Tabular for 2023 under the categories T74.- and T76.- there are notes to use additional code for any associated current injury if applicable. This is telling the coder that the injury is coded additionally/second.
• Female patient presents and states she was raped by her ex-boyfriend. She also has a fracture of her humerus from the incident. She was admitted and required surgery for the displaced right humerus fracture. At the time of discharge, the patient is diagnosed with humerus fracture and rape from suspected assault by ex-boyfriend. This case would be coded like the first scenario above. The ICD-10—CM code T76.21XA (Adult sexual abuse, suspected, initial encounter) is reported as the PDX followed by the code for the injury. In this case, there was physical injury and rape suspected. Per the Excludes1 Note in the ICD-10-CM Tabular, codes from T76- should not be used at the same time as codes from T74.-. The OCG stated in the scenario above would be followed.
• Child is brought into the ED with mother complaining that she picked the child up from her father earlier in the day with multiple bruises and crying. On examination, it is found that the patient has suffered a small subdural hematoma due to head injury. The patient is admitted as an inpatient and neurosurgery was consulted. The patient did not require surgery at this time. The final diagnosis on discharge is subdural hematoma due to suspected child abuse from the father. Social services are involved in the case as well as Child Protective Services. In this case, the code T76.12XA (Child physical abuse, suspected, initial encounter) is reported as the PDX followed by the code for the subdural hematoma. This is based on the OCG stated above.
• Female patient presents at 6 months pregnant due to being struck multiple times in the stomach by her boyfriend. She is admitted to inpatient, and the baby is monitored. There is good fetal movement and reassuring fetal heart beats. After a few days of monitoring, the patient is discharged with the diagnosis of abdominal wall contusions due to physical abuse by boyfriend. In this case, the coder would report a code from Chapter 15 (O9A.3-, O9A.4-, OR O9A.5-) instead of the T74.- or T76.- for the abuse during or complicating the pregnancy.

If the abuse is confirmed, also report the external cause code to identify the perpetrator (Y07.-). Remember these codes are only used on the confirmed cases of abuse and not on suspected cases. When selecting the specific perpetrator, the code is based on the relationship between the perpetrator and the victim.

If the abuse is ruled out, coders would report the appropriate Z code for the ruled-out condition. Z04.71 or Z04.72 for the ruled-out child or adult physical abuse. Z04.41 or Z04.42 for the ruled-out child or adult sexual abuse. Z04.81 or Z04.82 for the ruled-out child or adult psychological abuse.

Stats and Interesting Information (although sad since everyone is entitled to live without abuse from anyone)

• Adults with a history of child abuse often suffer from PTSD, eating disorders, low self-esteem, depression, anxiety, other mental illness, drug or alcohol use, anger towards others, guilt, physical illness, and learning disabilities.
• Physical child abuse remained a hidden problem until 1962.
• 30% of children with severe abuse meet the criteria for ADHD.
• Physical neglect is the most common type of neglect.
• Approximately 7 million children are abused or neglected each year.
• Babies less than a year old have the highest rate of abuse or neglect.
• Most children that are abused are less than 3 years old.
• One in 20 boys will be sexually abused before they are 18.
• One in 5 girls will be sexually abused before they are 18.
• 90% of the time the child will know their sexual abuser.
• One in 20 children will suffer physical abuse in their lifetime.
• Emotional abuse is the most common type of abuse.
• Approximately 20 persons per minute are physically abused in the U.S.
• One in every 4 females and one in every 9 males are abused severely.
• The most common age for a female to be abused is 18-24.

National Domestic Violence Hotline
Phone: 800-799-7233
SMS: Text START to 88788

National Center for Missing & Exploited Children’s Cyber Tipline
Phone: 800-843-5678

Each state also has a hotline for reporting domestic and/or child abuse.

Coders should review the entire patient record to ensure that the relationship between the injury and the abuse, neglect, or maltreatment is clearly documented. Best practice is to code it right from the start.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

References
https://healthline.com/health/signs-of-mental-abuse
https://arkofhopeforchildren.org/child-abuse/child-abuse-statistics-info
https://www.thehotline.org/
https://www.priorygroup.com/blog/how-child-abuse-affects-adult-survivors
https://dana.org/article/wounds-that-time-wont-heal
https://www.continued.com/early-childhood-education/ask-the-experts/what-neglect-and-types-there-23084
https://www.childwelfare.gov/topics/can/impact/consequences-can
https://www.healthychildren.org/English/safety-prevention/at-home/Pages/What-to-Know-about-Child-Abuse.aspx
https://kalimunro.com/wp/articles-info/sexual-emotional-abuse/emotional-abuse-the-most-common-form-of-abuse
https://www.aapc.com/codes/icd-10-codes/T76
https://ncadv.org/STATISTICS
ICD-10-CM and ICD-10-PCS Coding Handbook
ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 Pages: 42 & 43
AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Page: 12

Since 1992, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.