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2025 ICD-10-CM code Z04.71

Encounter for examination and observation following alleged adult physical abuse, ruled out.

Code Z04.71 should only be used when the alleged adult physical abuse has been ruled out after examination and observation. Do not use this code if abuse is confirmed or if the case remains under suspicion. Ensure the documentation clearly supports the decision to rule out abuse.

Medical necessity for using this code is established when a patient presents with signs or symptoms suggestive of adult physical abuse, requiring examination and observation to determine if abuse has occurred.

The clinician is responsible for conducting a thorough examination and observation of the patient following alleged adult physical abuse. This may include documenting the patient's history, physical findings, and any diagnostic tests performed. It is crucial to differentiate between suspected, confirmed, and ruled-out cases of abuse and apply the appropriate code accordingly.

IMPORTANT:For confirmed cases of adult physical abuse, use codes T74.-. For suspected cases of adult physical abuse, not ruled out, use codes T76.-. For encounters related to alleged adult sexual abuse, use Z04.41.

In simple words: This code is used after someone has been examined for possible physical abuse, but the doctor determined they weren't abused.

This code is used when a person encounters health services for examination and observation following alleged adult physical abuse, which is subsequently ruled out.It excludes confirmed cases of adult physical abuse (T74.-), encounter for examination and observation following alleged adult sexual abuse (Z04.41), and suspected cases of adult physical abuse, not ruled out (T76.-).

Example 1: A 65-year-old female presents to the emergency department with bruising on her arms. Her caregiver claims the patient fell, but the pattern of bruising raises concerns for physical abuse. After a thorough examination, including imaging and consultation with social services, the physician determines that the bruising is consistent with a fall and rules out abuse., An 80-year-old male is brought to the clinic by his son for a routine check-up. The son expresses concern about possible neglect by the patient's nursing home staff.The physician performs a comprehensive examination and finds no evidence of neglect., A 70-year-old female presents to the hospital with a fractured hip.During the examination, the physician notices signs that could indicate abuse. After further investigation, including interviews with the patient and family members, the physician determines that the fracture was caused by a fall and not physical abuse.

Documentation should include details of the alleged abuse, the patient's history and physical examination findings, results of any diagnostic tests performed (e.g., imaging, laboratory tests), consultations with other healthcare professionals or social services (if applicable), and the rationale for ruling out physical abuse.

** This is a billable code.

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