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2025 ICD-10-CM code Z04.41

Encounter for examination and observation following alleged adult rape; suspected adult rape ruled out.

Follow official ICD-10-CM coding guidelines.Ensure that the documentation clearly supports the use of Z04.41.If a sexual assault is confirmed, use the appropriate codes from the T74 or T76 categories instead. A corresponding procedure code must accompany Z04.41 if a procedure was performed.

Modifiers may be applicable to any procedures performed during the examination.

Medical necessity is established by the patient's report of a sexual assault, necessitating a thorough examination to assess for injuries, rule out the assault, and provide necessary medical care. The examination is deemed medically necessary to meet the patient's immediate health needs and to provide appropriate follow up care.

The clinical responsibility includes conducting a thorough physical examination of the patient to assess for any injuries or signs of trauma related to the alleged rape.This may involve collecting forensic evidence, documenting findings, and providing appropriate medical care.The physician may also provide counseling and support to the patient.

IMPORTANT:If the rape is confirmed, use codes from subcategory T74.2 (Adult sexual assault). If the rape is suspected but not ruled out, use codes from subcategory T76.2 (Adult sexual assault).

In simple words: This code is used when someone has been examined after a claim of rape, but the examination shows no evidence of rape.

This code is used when an adult patient presents for examination and observation following an allegation of rape.The examination and observation are conducted to assess for injuries or other conditions, but after evaluation, the rape is ruled out. This code is also applicable for administrative and legal observation statuses.It's used when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out.

Example 1: A 25-year-old female presents to the emergency department after reporting a sexual assault. A complete physical examination, including a forensic examination, is performed. No evidence of sexual assault is found.Z04.41 is assigned., A 30-year-old female is brought to the hospital by law enforcement following an alleged rape.A comprehensive physical exam reveals no injuries consistent with sexual assault. Z04.41 is assigned., A 40-year-old female reports a sexual assault to the police and undergoes a medicolegal examination. After the examination, it is determined that no sexual assault occurred. Z04.41 is assigned.

Detailed documentation of the patient's history, including the circumstances surrounding the alleged assault.A comprehensive physical examination report detailing the findings of the examination, including any injuries or lack thereof. Documentation of any forensic evidence collected and the results of any tests performed.A clear statement indicating that the rape is ruled out after examination and observation.

** This code should only be used when the alleged sexual assault is ruled out after a thorough examination.Use of this code requires detailed documentation to support the clinical findings.

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