ICD-10 Coding for Sexual Assault(T74.2, T74.21, T74.21I)
Explore comprehensive ICD-10 coding guidelines for sexual assault, including confirmed and suspected cases, with detailed documentation requirements.
Complete code families applicable to Sexual Assault
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
Essential facts and insights aboutSexual Assault
Alternative codes to consider when ruling out similar conditions
Documentation & Coding Risks
Avoid these common issues when documenting Sexual Assault.
Ambiguous documentation of assault status
Impact
Clinical: Leads to incorrect treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation
Use specific language to indicate confirmation or suspicion., Ensure thorough documentation of clinical findings.
Incorrect sequencing of injury codes before T74.21
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
Always sequence T74.21 before any injury codes.
Using T74.21 and T76.21 together
Impact
Reimbursement: May result in claim denial., Compliance: Violates ICD-10 Excludes1 note., Data Quality: Confusion in clinical data interpretation.
Mitigation
Choose either T74.21 or T76.21 based on confirmation status.
Incorrect code sequencing
Impact
Failure to sequence T74.21 before injury codes.
Mitigation
Implement coding audits to ensure correct sequencing.
Frequently Asked Questions
Primary Code
Adult sexual abuse, confirmed, initial encounterAAdult sexual abuse, suspected, initial encounterAEncounter for examination and observation following alleged adult rap