ICD 10 Coding Alert

Navigate contrary ICD-10-CM instructions with confidence.

Encountering abuse can bring up a lot of feelings, but frustration with the ICD-10-CM guidelines doesn’t need to be part of the experience.

Pocket these tips for navigating instructions that can be confusing.

Nuts and bolts: ICD-10 Guideline IV.H tells you not to “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

Whether this rule applies in all situations, however, is something that confronts coders from time to time. For example, does Guideline IV.H rule apply in cases of abuse, such as child neglect or maltreatment when they are suspected and eventually ruled out?

Consider these examples.

Is This Suspected Abuse?

During an examination of a 13-year-old patient, the provider discovers extensive bruising around the child’s buttocks and left thigh. The provider initially suspects that the child’s father has physically abused him, based on observations of how the child refused to talk about the incident that caused the injuries and the child’s body language toward his father. The provider documents that the child may have been physically abused.

However, subsequently the child explains that they had received the injuries following a fall from their bicycle. They said they didn’t want to talk about them initially as they had been with friends their parents had told them not to be with, and in a part of town they were not supposed to go.

Here’s How to Code This Scenario

Clearly, the first codes that come to mind for this encounter are injury and external cause codes. “In this case, I would code S30.0XXA [Contusion of lower back and pelvis, initial encounter] and S70.12XA [Contusion of left thigh, initial encounter] and add a corresponding external cause code,” such as V18.2XXA (Unspecified pedal cyclist injured in noncollision transport accident in nontraffic accident, initial encounter) says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

The issue then becomes, from a coding perspective, what should you do about the physical abuse that your provider suspected?

Does Guideline I.C.19.f. Take Precedence Over IV.H?

Simply put, there are a number of ICD-10 codes that will override guideline IV.H based on the fact that they include the words “suspected” or “ruled out.”

In this case, though, that may lead you to code the scenario incorrectly. Guideline I.C.19.f., says that when the documentation in the medical record states the abuse or neglect is suspected “it is coded as suspected and documented as suspected (T76.-).” The guideline also tells you to “sequence first the appropriate code from categories T74 … or T76 … followed by any accompanying mental health or injury code(s).”

But, before reaching for T76.12XA (Child physical abuse, suspected, initial encounter) and sequencing it as the first-listed code ahead of the three other codes already selected to document the encounter, you need to read further into the guideline. There, you are told that “if a suspected case of abuse, neglect or mistreatment is ruled out during an encounter,” you should code Z04.72 (Encounter for examination and observation following alleged child physical abuse), “not a code from T76.”

Yet even using that code would be incorrect “since there was no abuse alleged and the abuse suspected by the provider was ruled out and there were only symptoms of the injury present,” says Wolf. So, you are left simply using the two injury codes and the external cause code to document the scenario.

Rely on Provider Judgment

Ultimately, this has to be a judgment call on the provider’s part. Factors such as family or personal history of abuse, an examination inconsistent with the patient’s chief complaint, or even legal considerations, such as mandatory state abuse reporting requirements, could possibly come into play as may the circumstances under which the patient is presented to the provider (e.g., if an accompanying parent or caregiver alleges abuse of the patient by another individual). In other words, even though you can use guideline I.C.19.f. to override IV.H doesn’t mean you need, or even should, use it in all cases of suspected abuse when your provider rules it out.