ICD-10 Coding for Sexual Assault(T74.21XA, T76.21XA, Z04.41)
Complete ICD-10-CM coding and documentation guide for Sexual Assault. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sexual Assault
T74.2-T74.21Primary Range
Confirmed sexual abuse by adult
Used for confirmed cases of sexual assault where evidence supports the claim.
Suspected sexual abuse by adult
Used for cases where sexual assault is suspected but not confirmed.
Examination and observation following alleged rape
Used for examinations after an alleged sexual assault without confirmed injury.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| T74.21XA | Adult sexual abuse, confirmed, initial encounter | Use when sexual assault is confirmed by clinical or forensic evidence. |
|
| T76.21XA | Adult sexual abuse, suspected, initial encounter | Use when sexual assault is suspected based on patient report but lacks confirmatory evidence. |
|
| Z04.41 | Encounter for examination and observation following alleged adult rape | Use when a patient is examined following an alleged rape without confirmed injury. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for confirmed sexual assault
Essential facts and insights about Sexual Assault
Primary ICD-10-CM Codes for sexual assault
Decision Criteria
clinical Criteria
- Presence of forensic evidence or physical findings
documentation Criteria
- Detailed description of assault circumstances
Applicable To
- Confirmed sexual assault
Excludes
- Suspected sexual abuse (T76.21)
Clinical Validation Requirements
- Forensic evidence of assault
- Physical findings consistent with forced penetration
Code-Specific Risks
- Misclassification if documentation is insufficient
Coding Notes
- Ensure documentation clearly supports the confirmed status of the assault.
T76.21XA - Adult sexual abuse, suspected, initial encounter
Use when sexual assault is suspected based on patient report but lacks confirmatory evidence.
Applicable To
- Suspected sexual assault
Excludes
- Confirmed sexual abuse (T74.21)
Clinical Validation Requirements
- Patient reports assault without confirmatory evidence
Coding Notes
Ensure documentation reflects the suspicion without confirmation.
Z04.41 - Encounter for examination and observation following alleged adult rape
Use when a patient is examined following an alleged rape without confirmed injury.
Applicable To
- Examination after alleged rape
Excludes
- Confirmed or suspected sexual abuse (T74.21, T76.21)
Clinical Validation Requirements
- Patient presents for examination after reporting rape
Coding Notes
Ensure documentation specifies the examination context.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sexual Assault to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code T74.21XA.
Impact
Clinical: Leads to incorrect treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Use specific language to indicate confirmation or suspicion., Ensure thorough documentation of clinical findings.
Impact
Reimbursement: Incorrect sequencing can lead to lower reimbursement rates., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data reporting and analysis.
Mitigation Strategy
Always sequence T74.21 before any injury codes.
Impact
Reimbursement: May result in claim denial., Compliance: Violates ICD-10 Excludes1 note., Data Quality: Confusion in clinical data interpretation.
Mitigation Strategy
Choose either T74.21 or T76.21 based on confirmation status.
Impact
Failure to sequence T74.21 before injury codes.
Mitigation Strategy
Implement coding audits to ensure correct sequencing.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Sexual Assault, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sexual Assault
Use these documentation templates to ensure complete and accurate documentation for Sexual Assault. These templates include all required elements for proper coding and billing.
Emergency Department Encounter for Sexual Assault
Specialty: Emergency MedicineRequired Elements
- Patient history
- Details of the assault
- Physical examination findings
- Forensic evidence collected
- Perpetrator information if known
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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