2025 ICD-10-CM code T76.2
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Sexual abuse, suspected 19 Feed
Suspected sexual abuse. Suspected rape.
Medical necessity for using this code is established when there is clinical suspicion of sexual abuse or rape based on patient presentation, history, and examination findings. Further investigation and documentation are crucial to confirm or rule out the suspected abuse.
Clinicians should document all signs, symptoms, and findings related to the suspected abuse. A thorough physical exam should be performed, and any evidence should be collected and preserved. Clinicians have a responsibility to report suspected abuse to appropriate authorities, as required by law.
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- Injury, poisoning and certain other consequences of external causes (S00-T88)Other and unspecified effects of external causes (T66-T78)
In simple words: This code is used when there is suspicion or reason to believe that a person has experienced sexual abuse or rape, but it has not yet been confirmed.
Suspected sexual abuse. Suspected rape.
Example 1: A child presents with unexplained genital injuries and behavioral changes. The physician suspects sexual abuse., An adult patient discloses to their therapist that they were sexually assaulted a week prior. The therapist documents suspected sexual abuse., A patient presents to the emergency room with injuries consistent with sexual assault. They are unable to provide a clear history due to intoxication. The physician documents suspected rape.
Documentation should include details of the physical examination findings, any reported symptoms or behaviors suggestive of abuse, and any other relevant information, such as witness statements. It is crucial to document whether the abuse is confirmed or suspected.
- Payment Status: Active
- Specialties:Emergency Medicine, Pediatrics, Family Medicine, Internal Medicine, Obstetrics and Gynecology, Psychiatry
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Telehealth Provided in Patient’s Home