Challenges of Coding “Child Abuse”

Nonaccidental trauma (NAT) should code to “child abuse, suspected or confirmed.”

The challenges of coding “child abuse, suspected or confirmed” is becoming a source of increased interest for me. When ICD-10 rolled out, as among the changes was a coding guideline that included a code for “child abuse” (and any time I say “child abuse,” please understand that I mean suspected or confirmed). Also with that change came the guideline that “child abuse” would be the principal diagnosis, resulting in the correct DRG.

My work as a clinical documentation improvement specialist (CDIS) at a level 1 pediatric trauma center includes reviewing pediatric ICU records, which is where the critical trauma patients are admitted. A certain percentage of those trauma patients are identified as “non-accidental traumas,” known by the acronym NAT. And NAT can’t be coded.

When I initially encountered NAT cases, I looked into what exactly NAT meant. In doing research, I found that the term was used by practitioners as accepted verbiage for patients whose injuries were thought to be inflicted – in other words, suspected child abuse. It bothered me that it was a euphemism, if you will, for a victimized child – which made things even more confusing for me, because at our facility, when a child is considered a NAT admission, there is a highly choreographed series of events that ensue, including a social work consult, an internal child protective services consult, a referral to government child welfare agencies, and a call to the authorities in the locale where the injury is thought to have occurred. It is a swift and precise response triggered for the sake of advocating for and protecting a child who is in need of safekeeping. And yet the documentation didn’t take me to the correct code. So I reached out to Dr. (Erica) Remer and filled her in on what I was seeing.

The pediatric trauma team at our facility is a group of highly dedicated and clinically respected surgeons whose work for all children is tireless. So I started by speaking with them to ask why they were so liberal with the term NAT rather than documenting “suspected child abuse.” The responses that I got were a) “suspected child abuse” is inflammatory, and b) that “child abuse” was a legal term, and they as physicians didn’t want to be making any legal determinations.

My response to that was, huh, what is more inflammatory than a victimized child…and then pointing out the irony in using NAT, which leaves no doubt that the injuries sustained were inflicted upon the patient, or in other words, not accidental. The term “suspected child abuse” doesn’t indict or convict anyone; it states exactly what the clinical facts are and leads to the correct coding path.

Fortunately, the trauma team, the first line of providers and usually the team that starts documenting NAT, has begun to appreciate my concerns, and this is reflected in most of their documentation. But I still face unnecessary queries, particularly when I query an attending who is not on the trauma team, such as a PICU attending. 

So, if NAT is not a term that is going to going to be abandoned anytime soon, maybe there should be a way to have it be included as a term that can code to “child abuse, suspected or confirmed.”

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