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2025 ICD-10-CM code Y07.9

Unspecified perpetrator of maltreatment and neglect.

This code should always be a secondary code, used in conjunction with a primary code describing the nature of the injury or condition.Never use Y07.9 alone.

No modifiers are applicable to external cause codes.

Medical necessity for the associated diagnoses (e.g., injuries, malnutrition, psychological trauma) should be documented separately, according to the specific condition.Y07.9 helps identify that the underlying cause is maltreatment/neglect by an unspecified perpetrator.

Clinicians should use this code to indicate the external cause of the injury or condition documented with a code from another chapter.

In simple words: This code is used when someone has been hurt or harmed due to maltreatment or neglect, but it's unknown who the person responsible for the harm was.

This code signifies an instance of maltreatment and neglect where the perpetrator remains unspecified.It is used to classify environmental events and circumstances as the cause of injury and other adverse effects.This code should be used secondary to a code from another chapter indicating the nature of the condition, most often Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T88).

Example 1: A child presents with multiple bruises and fractures.The cause of the injuries is suspected to be abuse, but the specific perpetrator cannot be identified.Code Y07.9 would be used in addition to the codes for the injuries., An elderly patient is admitted with signs of neglect, including malnutrition and dehydration. The responsible party is unknown. Y07.9 would be used along with the codes for the specific conditions., An adult patient presents with psychological trauma consistent with emotional abuse. The perpetrator is not identified. The code Y07.9 would be supplementary to the psychological diagnosis codes.

Documentation should clearly support the diagnosis of maltreatment and neglect. Detailed descriptions of physical findings, psychological evaluations, or other evidence of neglect/abuse are crucial. The documentation should also state that the perpetrator is unknown.

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