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2025 ICD-10-CM code Y07.5

Identifies a non-family member as the perpetrator of maltreatment and neglect.

This code is always secondary to the code describing the injury or condition.Ensure accurate identification of the perpetrator and appropriate documentation.Refer to official ICD-10-CM guidelines for complete coding instructions.

The medical necessity is established by the presence of injuries, conditions, or symptoms resulting from the maltreatment or neglect. This requires complete documentation to support the diagnoses and the reported circumstances.

Documentation of the perpetrator's identity and relationship to the victim is the clinical responsibility.This is crucial for legal and social services intervention.Accurate coding requires identifying the primary diagnosis stemming from the maltreatment and neglect (e.g., physical injuries, emotional distress). The physician or healthcare professional must ensure that all aspects of the incident are thoroughly documented.

IMPORTANT:Y07.54 (Acquaintance or friend, perpetrator of maltreatment and neglect) is a more specific code that can be used if applicable.

In simple words: This code is used when someone who is not a family member harms or neglects another person.It's added to another code that explains the type of harm done.

This ICD-10-CM code, Y07.5, specifies a non-family member as the perpetrator in cases of maltreatment and neglect.It is used as a secondary code alongside codes indicating the nature of the injury or condition resulting from the maltreatment or neglect (typically found in Chapters 19 (Injury, poisoning, and certain other consequences of external causes) or other chapters as appropriate).The code is crucial for documenting the circumstances surrounding the event, particularly for reporting and analysis of abuse and neglect cases.This code is supplementary and requires a primary code that describes the actual injury or condition.

Example 1: A 25-year-old female presents to the ER with multiple bruises and contusions after being physically assaulted by a former acquaintance.The primary diagnosis would reflect the injuries, while Y07.5 would be a secondary code identifying the assailant as a non-family member., A 10-year-old child is admitted for severe neglect, showing signs of malnutrition and dehydration.Y07.5 would be used as a secondary code to document the non-family member responsible for the neglect., An elderly patient is found to have sustained a fracture due to an intentional fall orchestrated by a non-family member caregiver. The primary diagnosis would code the fracture, and Y07.5 would document the perpetrator as a non-family member.

Thorough documentation is essential, including:

** This code is frequently used in conjunction with codes from Chapter 19 (Injury, poisoning and certain other consequences of external causes) to fully represent the clinical picture.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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