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2025 ICD-10-CM code Y07.4

Other family member, perpetrator of maltreatment and neglect.

This code should always be used in conjunction with codes describing the injury or condition resulting from the maltreatment.Use the most specific code available to capture the nature of the abuse or neglect.

Modifiers are not directly applicable to this code, as it describes the circumstance of the injury rather than the procedure or service provided.

The medical necessity for the codes depends on the injuries sustained.If the injuries are directly related to the abuse or neglect, the codes are medically necessary to accurately reflect the diagnosis.

The clinical responsibility involves documenting the nature and extent of the maltreatment or neglect, as well as the injuries sustained by the victim.This requires thorough history-taking, physical examination, and possibly imaging studies or other diagnostic tests.The physician may also need to coordinate with child protective services or other legal authorities.

IMPORTANT:This code has several more specific child codes under it to specify the exact relationship.Examples include Y07.410 (Brother, perpetrator of maltreatment and neglect), Y07.411 (Sister, perpetrator of maltreatment and neglect), Y07.420 (Foster father, perpetrator of maltreatment and neglect), Y07.421 (Foster mother, perpetrator of maltreatment and neglect), and others.The choice of code depends on the precise family relationship of the perpetrator.It is often used in conjunction with codes from Chapters 1-18 to specify the type of injury or condition resulting from the maltreatment.Consider using codes from Chapter 19 (Injury, poisoning and certain other consequences of external causes) to specify the injuries sustained.

In simple words: This code is used when a family member (other than a parent, spouse, or sibling) harms or neglects someone.It's added to a code describing the actual injury or problem caused by the abuse or neglect.

This ICD-10-CM code classifies the circumstance of maltreatment and neglect inflicted by a family member other than those specifically listed in other codes.It is used as a secondary code to indicate the perpetrator's relationship to the victim, alongside a primary code specifying the nature of the injury or condition resulting from the maltreatment.The code encompasses various forms of abuse, including physical, emotional, sexual, and neglect.

Example 1: A 10-year-old child is brought to the emergency room with multiple bruises and a fractured arm. The child reveals that their maternal uncle inflicted these injuries.Y07.4 would be used as a secondary code along with the appropriate codes for the fractures and bruises (Chapter 19). , An elderly woman is admitted to a nursing home with malnutrition and dehydration. It's discovered that her cousin, who was responsible for her care, failed to provide adequate nutrition and hydration. Y07.4 is used along with the ICD-10 codes for malnutrition and dehydration., A young adult is diagnosed with PTSD following years of emotional abuse from a grandparent.Y07.4 is used as a secondary code along with the ICD-10 code for PTSD (F43.10).

Complete documentation of the abuse or neglect is essential.This includes a detailed history of the events, physical examination findings, any imaging or laboratory results, and a statement of the victim’s and perpetrator’s relationship. If applicable, include reports from social services or other agencies involved in the case.

** This code is intended to be used as a secondary code, providing context to the primary code describing the injury or condition.Always ensure the selected codes accurately reflect the clinical situation and follow current coding guidelines.

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