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2025 ICD-10-CM code T74.21

Adult sexual abuse, confirmed.

Code T74.21 should be used as the principal diagnosis when the encounter is for the confirmed sexual abuse.If there are related injuries, those should be coded additionally.Use secondary codes from Chapter 20 (External causes of morbidity) to indicate the cause of the injury, including the perpetrator if known (Y07.-).Do not use this code with T76.21 (Suspected adult sexual abuse).

The medical necessity for using this code is based on the clinician's confirmation of adult sexual abuse.Appropriate documentation is required to support this diagnosis.This may include a detailed history, physical exam findings, psychological evaluations, or police reports.

Clinicians use this code when documenting cases of confirmed adult sexual abuse.It’s crucial to ensure proper documentation supports the use of this code.

IMPORTANT:Use additional external cause code to identify perpetrator, if known (Y07.-).If abuse is suspected, use T76.21

In simple words: This code is used when a healthcare provider has determined that an adult has experienced sexual abuse.

Adult sexual abuse, confirmed.

Example 1: A 30-year-old female patient presents to the emergency room reporting sexual assault that occurred earlier that day.A physical examination reveals injuries consistent with her account. After a thorough evaluation, the physician confirms the sexual abuse and assigns code T74.21., A 25-year-old male patient discloses to his therapist a history of sexual abuse during his childhood. The therapist, after several sessions and corroborating evidence, confirms the abuse. Although the abuse occurred in the past, the code T74.21 is still applicable as it reflects a confirmed diagnosis, regardless of when the abuse took place. , A 40-year-old individual is admitted to the hospital for a physical injury sustained during a sexual assault. Code T74.21 would be used in conjunction with codes describing the specific injuries. The T74.21 would be listed first.

Detailed documentation of the patient's history, physical examination findings, and any other supporting evidence that led to the confirmation of sexual abuse. It is essential to include details about the nature of the abuse, the time frame if possible, and any related injuries or psychological impacts.

** Excludes1: abuse and maltreatment in pregnancy (O9A.3-, O9A.4-, O9A.5-)

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