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2025 ICD-10-CM code T76.21

Suspected adult sexual abuse.

Use additional codes from Chapter 20 (External causes of morbidity) to indicate the cause of the injury. Use additional code Z18.- to identify any retained foreign body, if applicable. If the suspected abuse is ruled out, use Z04.41.

Use the 7th character to indicate the encounter type: A = initial encounter, D = subsequent encounter, and S = sequela.

Medical necessity is established by the clinician's professional judgment that the patient has likely experienced sexual abuse. This may be based on the patient's history, physical exam, and psychological state.

It is the clinician's responsibility to document the details of the suspected abuse, including any physical or psychological findings. Clinicians should also be aware of mandatory reporting requirements for adult sexual abuse in their jurisdiction.

IMPORTANT:For confirmed adult sexual abuse, use T74.21.

In simple words: This code is used when a healthcare professional suspects that an adult has been sexually abused.

Suspected adult sexual abuse.

Example 1: A 30-year-old female presents to the emergency room with emotional distress and vague physical complaints. During the examination, she discloses that she was recently sexually assaulted. Although physical evidence is limited, the physician suspects sexual abuse and assigns code T76.21., A 50-year-old male presents to his primary care physician with symptoms of anxiety and depression. After building rapport, he reveals he is a victim of ongoing sexual abuse by a caregiver. The physician documents the suspicion and uses code T76.21., An elderly patient in a nursing home exhibits signs of fear and withdrawal. Staff members suspect sexual abuse. After an initial assessment, the physician documents the suspicion with T76.21 while further investigation is pending.

Documentation should include details of the event, physical and psychological findings, and any other relevant information supporting the suspicion of sexual abuse. Any physical injuries or psychological trauma should be coded separately.

** It's essential to distinguish between suspected abuse (T76.21) and confirmed abuse (T74.21).This code should not be used if the abuse has been ruled out or if the patient is experiencing sexual harassment, which can be coded as Z56.81.

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