2025 ICD-10-CM code Z04.72
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Encounter for examination and observation following alleged physical abuse Chapter 20: Factors influencing health status and contact with health services Feed
Encounter for examination and observation following alleged child physical abuse; ruled out.
The medical necessity for this encounter is to evaluate the child for potential physical abuse. When the child is suspected of being abused, a thorough examination is medically necessary to determine the extent of any injuries and to provide appropriate medical care.If abuse is ruled out, this code is appropriate to reflect that the evaluation did not reveal evidence of physical trauma consistent with child abuse.
The clinical responsibility involves conducting a thorough physical examination of the child, documenting any findings (or lack thereof), and potentially ordering additional investigations (e.g., imaging, laboratory tests) to fully rule out physical abuse. The physician must document the reason for suspicion, the examination performed, and the conclusion that the abuse is ruled out.
- Chapter 20: Factors influencing health status and contact with health services
- Z04: Encounter for examination and observation for other reasons
In simple words: This code is used when a doctor examines a child because there are concerns about possible physical abuse. If the doctor finds no evidence of abuse, this code is used in the medical billing.
This code is used when a child is suspected of having experienced physical abuse, but after examination and observation, the abuse is ruled out.The examination may be for medicolegal reasons or to assess the child's condition. This code is used even if no specific diagnosis is made; the key is that the encounter is for the purpose of evaluating alleged physical abuse.
Example 1: A 3-year-old child is brought to the emergency department after being found with unexplained bruising.A complete physical exam is performed, and no evidence of physical abuse is found. The physician documents the history of suspected abuse, the findings of the exam, and the conclusion that the abuse is ruled out.Z04.72 is used., A social worker refers a 5-year-old child to a pediatrician for evaluation due to concerns about neglect and potential physical abuse. The child is given a thorough physical, and no physical injuries are noted.Z04.72 is appropriate., A child is brought to a clinic after a caregiver reports that the child fell and hit their head.During the evaluation, no signs of trauma are found consistent with child abuse, and the suspected abuse is ruled out.Z04.72 is used.
* Detailed history of the suspected abuse including who reported the abuse and the reasons for suspicion.* Complete physical examination documentation, specifically addressing findings related to potential physical abuse.* Documentation of any additional investigations performed (e.g., imaging studies, lab tests).* Clear statement that child abuse is ruled out based on the findings of the evaluation.* If applicable, documentation of any explanation or alternative explanations for the suspected injuries.
** This code should be used cautiously and only when a thorough examination has been performed and the suspicion of child physical abuse is definitively ruled out.Adequate documentation is crucial to support the use of this code.
- Payment Status: Active
- Specialties:Pediatrics, Emergency Medicine, Family Medicine
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Other Place of Service