Child and adult abuse is a major concern in the U.S. and is often unreported. Better reporting is needed to discover the abused patient and enable more timely intervention because repetitive abuse is frequent. Every year in the U.S. more than 2 million cases of child abuse and neglect are reported, between 2 million and 4 million women are battered by their spouses, and between 700,000 and 1.1 million of the elderly population are abused. Patients who are victims of abuse often need services in addition to the treatment of physical injuries, such as counseling, safety planning and risk assessment.
There are four major types of abuse and neglect:
• Physical abuse
• Psychological or emotional abuse
• Sexual abuse
• Neglect (physical, emotional, educational, medical or social)
There are four major categories of codes that should be used when reporting incidents of abuse. These categories identify:
• The type of maltreatment or abuse
• The specific injury
• The nature of the abuse
• The perpetrator if known
Documentation must be accurate and complete for correct code assignment to occur. There should be a detailed description of the abuse, a complete history, physical examination findings, laboratory and other diagnostic procedure results, and risk assessment.
The Type of Abuse and Maltreatment
Codes from subcategories 995.5 and 995.8 are used to report the type of child or adult maltreatment or abuse. These codes allow the coder to indicate whether the abuse was physical, mental, sexual or neglect.
Codes for child abuse are found in subcategory 995.5, Child maltreatment syndrome:
• 995.50 Child abuse, unspecified
• 995.51 Child emotional/psychological abuse
• 995.52 Child neglect (nutritional)
• 995.53 Child sexual abuse
• 995.54 Child physical abuse
• 995.55 Shaken infant syndrome
• 995.59 Other child abuse and neglect
Coding Clinic, Fourth Quarter 1996, provides a detailed overview on the use of each of these child maltreatment codes.
Codes for adult abuse are found in subcategory 995.8, Other specified adverse effects, not elsewhere classified:
• 995.80 Adult maltreatment, unspecified
• 995.81 Adult physical abuse
• 995.82 Adult emotional/psychological abuse
• 995.83 Adult sexual abuse
• 995.84 Adult neglect (nutritional)
• 995.85 Other adult abuse and neglect
When a patient is presenting for treatment of abuse, the abuse code must be sequenced as the principal or first listed diagnosis. It is important to note that the physician must document abuse, neglect or maltreatment for these codes to be assigned by the coder. If the physician does not state the patient has been abused or maltreated, the above codes should not be assigned.
If a patient presents for evaluation of suspected abuse or neglect but none was found, assign code V71.81, Observation and evaluation for suspected abuse and neglect.
The Specific Injury
The specific type of injury should be coded next if documented. A code from subcategory 995.5 or 995.8 may be used alone if no injuries or signs or symptoms are present. However, it is extremely important that additional codes be used if there is documentation of associated diagnoses to allow for detailed data collection of the child and adult abuse.
Bruises or contusions are the most common evidence of physical abuse and they need to be distinguished from accidentally acquired bruises. In children these bruises are most frequently found on the buttocks and on the posterior surfaces of the thorax, lumbar area, thighs and calves. Other common injuries of child abuse are burns and fractures of the extremities, skull or ribs and traumatic injuries to the genitalia. The most common adult abuse injuries are of the head, face, neck, breasts and abdomen. Battered women often have injuries to the upper extremities, which occur as they try to defend themselves. Social withdrawal, depression or weight loss and dehydration may be signs of elderly abuse, neglect or maltreatment.
For example, if a patient received a dislocated shoulder after being pushed to the ground by her boyfriend, code 831.00, Closed dislocation, shoulder, is assigned to identify the specific type of injury.
The Nature of the Abuse and the Perpetrator
Coding Clinic, Fourth Quarter 1996, p. 77, states that an E-code to identify the nature of the abuse should be listed next, after the abuse and injury codes, followed by another E-code to identify the perpetrator.
Report the nature of the child or adult abuse from categories E960-E966 and E968, Homicide and injury purposely inflicted by other persons. For example, if a plate is thrown at the victim of abuse, assign code E968.2, Assault by striking by blunt or thrown object.
If the term sexual molestation or assault is used to indicate the nature of abuse, assign code E968.8, Assault by other specified means. If the term rape is used, assign code E960.1, Rape. These instructions are included on Coding Clinic, Third Quarter 1999, p. 15.
Finally, if known, an E code from category E967, Perpetrator of child and adult abuse, should be assigned next to identify the person who committed the abuse. For example, if the person who committed the abuse is a boyfriend assign code E967.0, Perpetrator of child and adult abuse, by father, stepfather or boyfriend.
History of Abuse
It is appropriate to assign one of the following history codes if there is a documented history of abuse.
• V15.41 History of physical abuse and rape
• V15.42 History of emotional abuse
• V15.49 History of other abuse
A history code should not be used if the original abuse injury is still being treated. However, if the patient presents with a new injury and there is also documentation of previous abuse then codes for both the current encounter and the history of abuse may be assigned to correctly reflect these circumstances.
Additional information on coding child and adult abuse/neglect can be found in Coding Clinic: Fourth Quarter 2000, p. 62; Third Quarter 1999, pp. 14-16; First Quarter 1998, p. 11; and Fourth Quarter 1996, pp. 38-45 and 77.
Test your knowledge with the following quiz:
1. A woman is seen in the emergency department (ED) for sutures after her husband strikes her in the head with his fist. She reports that he is often violent and becomes physically abusive at times. The diagnosis is listed as battered wife syndrome with laceration of the right eyebrow. How should the diagnoses for this case be coded?
a. 995.81, 873.42, E960.0, E967.3
b. 873.42, 995.81, E967.3, E960.0
c. 873.42, 995.81
d. 995.81, 873.42, E967.3
2. A 4-month-old baby is seen in the ED with the diagnosis of shaken infant syndrome. The baby was unconscious for approximately 1 hour after being shaken by the mother when she didn’t know how to stop the baby from crying. The physician also documents subdural hematoma and retinal hemorrhage in addition to the shaken infant syndrome. How should the diagnoses for this case be coded?
a. 995.55, E960.0, E967.2
b. 995.55, 852.23, 362.81, E968.8, E967.2
c. 995.55, 852.23, 362.81, E967.2
d. 995.55, 852.23, E967.2
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).
CPT is a registered trademark of the American Medical Association.
1. a. Assign diagnosis code 995.81 to report adult physical abuse. Code 873.42 is assigned to report the eyebrow lacerations. Codes E960.0 and E967.3 are assigned to identify the nature of the abuse and to identify the spouse as the perpetrator.
2. b. Assign codes 995.55, Shaken infant syndrome to identify the type of child maltreatment. Assign codes 852.23. Subdural hemorrhage following injury without mention of open intracranial wound, with moderate loss of consciousness, and 362.81, Retinal hemorrhage, to identify the associated injuries. Code E968.8, Assault by other specified means, is assigned to identify the nature of the abuse and code E967.2, Child and adult battering and other maltreatment, by mother or stepmother, is assigned to identify the mother as the perpetrator.