Coding and Documenting Child Abuse and Neglect

HIM coding can play a part in stopping the abuse and neglect of children

Marking April as National Child Abuse Prevention Month, we note that the Center for Disease Control (CDC) reports that child abuse and neglect are significant public health issues in the United States. The CDC reports that 1,750 children expired from abuse or neglect in 2016. One in four children experience abuse or neglect in their lifetime and one in seven children have experienced abuse or neglect in the past year. Those numbers are staggering to assimilate!

The CDC has published a set of strategies to address child abuse and neglect. The goal of their strategies is to raise awareness of the subject, use data to inform actions, create context for healthy children and families through programs to change norms, and create context for healthy children and families through policies. The strategies include strengthening economic family supports, changing social norms to support positive parenting, provide quality care and education early in life, enhance parenting skills to promote healthy child development, and intervene to reduce harms and prevent future risk. 

Child abuse and neglect have impacts beyond the initial injuries. The CDC reports that a total lifetime cost associated with one year of confirmed child abuse and neglect cases is $124 billion. That is a significant impact to the US budget for Health and Human Services.

During this month, take the time to review the coding of child abuse and neglect. Here are some steps to assist in this review:

1. Review the Official Coding Guidelines, I.C.19.f, which discuss the coding of child abuse, neglect, and other maltreatment.
2. Review your hospital’s specific guidelines regarding the coding of child abuse and neglect.

ICD-10-CM Official Coding and Reporting Guidelines

One of the first items that the coder must discern is if the abuse is confirmed (T74) or suspected (T76). For confirmed cases, the external cause code section (X92 – Y09) should be reported along with documented injuries. A perpetrator code (Y07) is reported when the person who performed the abuse/neglect is known. For suspected but not confirmed cases, the perpetrator is not reported. The code identifies the relationship between the perpetrator and the victim.  

If the suspected case is ruled out, then the coder should report Z04.72 (encounter for examination and observation following alleged child physical abuse, ruled out). The code from category T76 would not be reported. 

If the suspected case is an alleged rape or sexual abuse that is ruled out, Z04.42 (encounter for examination and observation following alleged child rape) should be used. Again, the code from category T76 would not be reported.  

Hospital/Organization-Specific Guidelines

Your hospital/organization-specific guidelines may not conflict with the ICD-10-CM Official Coding and Reporting Guidelines. Identify the documentation that may be used from the electronic health record. According to the classification, abuse and neglect can be physical, sexual, or psychological. Identify what constitutes a confirmed case of child neglect/abuse. Define for your organization what is child maltreatment. ICD-10-CM is a very specific coding classification system, but there are some gray areas that require definition at the facility level. Compare data with the Quality Department. Validate that the coding is consistent with reported data from the organization.

During Child Abuse Prevention Month and throughout the year, let’s remember HIM coding can play a part in stopping the abuse and neglect of children.

Program Note

Listen to Talk Ten Tuesday today and listens as Laurie Johnson reports on the coding and documentation of child abuse and neglect.