Reporting Elder Abuse on the Claim

Part 4 in a series of articles to support World Elder Abuse Awareness 

Written by Joy Rose, MSA, RHIA, CCS, CHA, CHPS     

ICD-10-CM Rules for Coding Abuse

World Elder Abuse Awareness Day was June 15.  Adult and child abuse, neglect and other maltreatment is unfortunately prevalent in society, and many believe that these cases are underreported (refer to the June 2024 article “Detecting Abuse of the Elderly” Part 2 in a series of AIHC Elder Abuse Awareness Training for your Workforce articles).  It is not uncommon for providers to evaluate suspected or confirmed cases of elder abuse.  Please feel free to repost, print and make this article available to your workforce members.

ICD-10-CM CODING RULES FOR ELDER ABUSE

When it comes to medical coding, there are specific codes that cover many types of abuse and exploitation.  These codes should always be assigned when appropriate. 

As a medical coder, when reviewing the medical record for appropriate documentation, one can only assign the codes when they are documented by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). Do not interpret the physician narrative without the physician’s confirmation.

When assigning codes to a medical record that has suspected, confirmed or sequelae effects from abuse, one should follow the coding guidance as found in the conventions of the ICD-10-CM book, the Official Coding Guidelines for ICD-10-CM, as published by the National Center for Healthcare Statistics and The American Hospital Association, Coding Clinic©.  The ICD-10-CM diagnosis codes applicable to a case of confirmed or suspected elder abuse can be found in the section, Coding of Injuries, Burns, Poisoning, and Complications of Care, CHAPTER 19 Injuries, in ICD-10-CM.

CODING AXIS OR PLACES IN ICD-10-CM

Remember the axes of ICD-10?  In coding abuse, the first axis is abuse, neglect or other maltreatment of an adult and whether the abuse is confirmed (category T74) or suspected (category T76).  Only select these categories when it is documented by the patient’s provider in the record.

CODE EXAMPLE OF SUSPECTED ELDER FINANCIAL ABUSE CODE:

• A suspected case of adult financial abuse code would start with the first axis abuse, suspected =T76
• The fourth character would indicate the type of abuse – financial T76.A (Financial)
• The fifth character specifies adult as the victim  T76.A1 (Adult)
• The sixth character indicates suspected – T76.A1X (Suspected)
• The 7^th character indicates the episode or encounter in this case initial.  T76.A1XA (episode)

For confirmed cases of abuse, be sure to assign the appropriate external cause codes from the assault section (X92-Y09) to identify the cause of physical injuries.  The perpetrator, when known, should also be added as a code from the Y07 category.

LOOK UP CONVENTION FOR ABUSE ICD CODES: 

• To find the code use the search term ‘maltreatment’, ‘abuse’, ‘exploitation’ as a start. When using an encoder, it may provide a code when entering a full term such as “financial abuse”. 

SEQUENCING:  

• Follow the coding guidelines for coding of injuries in Section 1, Chapters 19, 15, and 20; as well as the conventions of ICD-10 in the codebook.

WHAT ABOUT SUSPECTED CASES?

The assignment for suspected cases is slightly different. If suspected abuse is ruled out during a visit, assign code Z04.71-Encounter for examination and observation following alleged physical adult abuse, ruled out.   

• The “Z” category codes for ruled out, should be used, not a code from T76.
• If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41,
• Encounter for examination and observation following alleged adult rape or code Z04.42.
• If a suspected case of forced sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82

CODING SCENARIO

An elderly woman presents at the emergency department for pain in her left wrist.  Upon examination and x-ray, it is discovered she has a closed radial styloid process fracture. She relates the story as her wrist being grabbed and twisted by her adult daughter as the elderly woman attempted to keep the daughter from obtaining her debit card. The friend who brought the woman in witnessed the encounter and agrees with the story.  A police report has been filed. The physician documents the abuse as confirmed.

The codes assigned based on documentation in the patient’s medical record would be:

S52515A  Nondisplaced fracture of left radial styloid fracture, closed

T7411XA  Adult physical abuse, confirmed initial encounter

T74A1XA  Adult financial abuse confirmed initial encounter

Y042XXA  Assault by strike against or bumped into by another person, initial encounter

Y0744  child perpetrator of maltreatment and neglect

A coder should also code the social determinants of health for this encounter, if any. In this case, Z62820 Parent-biological child conflict, might be used.

References:

• AHA CODING CLINIC, First Quarter 2023, Fourth Quarter 2018, and Fourth Quarter 2016, American Hospital Association
• OFFICIAL CODING GUIDELINES AS PUBLISHED BY THE NATIONAL CENTER FOR STATISTICS, CDC 2024; , ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 Page 83 of 120, https://stacks.cdc.gov/view/cdc/150422
• National Adult Maltreatment Reporting System, National Adult Maltreatment Reporting System

About the Author

Joy Rose, MSA, RHIA, CCS, CHA, CHPS is a member of the American Institute of Healthcare Compliance (AIHC) and serves as a subject matter expert on the AIHC Volunteer Education Committee.