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2025 ICD-10-CM code Z04.42

Encounter for examination and observation following alleged child rape.

A corresponding procedure code must accompany a Z code if a procedure is performed. Do not report Z04.42 if a diagnosis of abuse is confirmed, in which case a code from the T74 category is appropriate. If suspected abuse is ruled out during the encounter, do not report a code from T76. External cause codes (V-Y) should not be reported with Z codes.

The medical necessity for this code is based on the need to evaluate a child for potential physical and psychological harm following an alleged sexual assault. This evaluation is essential to ensure the child's safety and well-being.

The clinician is responsible for examining the child, documenting findings, ordering any necessary tests, and determining if further medical or psychological intervention is needed. They are also responsible for ensuring appropriate reporting procedures are followed if abuse is suspected.

In simple words: This code is used when a child needs to be checked by a doctor after someone says they were raped. The doctor will examine the child and watch them for a while to decide if they need more tests or treatment.

This code is used when a child is examined and observed following an alleged rape.It is used when a person without a confirmed diagnosis is suspected of having an abnormal condition, without presenting signs or symptoms, which requires study, but after examination and observation, is ruled-out. This code can also be used for administrative and legal observation status.

Example 1: A 5-year-old child is brought to the emergency department by their parent after disclosing they were sexually assaulted by a family friend. The child undergoes a physical examination and is observed for any immediate medical concerns. The code Z04.42 is used to document the reason for the encounter., A 10-year-old child is brought to a clinic by child protective services following a report of suspected sexual abuse. The child is examined, but no physical findings confirm the abuse.The code Z04.42 is used as the child was examined for suspected abuse, which, after examination and observation, was ruled-out., A 7-year-old child, after an examination and observation, is found to not have been a victim of sexual abuse, as initially reported. Z04.42 would be the appropriate code to describe the situation as the child required study, but after examination and observation, abuse was ruled-out.

Documentation should include a detailed history of the alleged event, including the date, time, location, and alleged perpetrator. The physical examination findings should be thoroughly documented, including any injuries or signs of trauma.Any laboratory or imaging results should also be included.

** It is crucial to follow mandatory reporting guidelines in cases of suspected child abuse.This typically involves contacting child protective services or law enforcement.

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