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2025 ICD-10-CM code T74.2

This code represents confirmed sexual abuse.

Use additional external cause code to identify perpetrator, if known (Y07.-). Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Use additional code to identify any retained foreign body, if applicable (Z18.-).

Medical necessity for services related to sexual abuse is determined by the need for treatment of the physical and psychological effects of the trauma. This can include medical examinations, treatment of injuries, mental health counseling, and other therapeutic interventions.

Clinicians have a responsibility to document the details of the abuse, provide appropriate medical care, and report the incident to the relevant authorities.They should also offer support and resources for psychological and emotional healing.

In simple words: This code is used when someone has been forced into sexual activity against their will. This is a serious crime with potentially long-lasting physical and emotional effects.

Sexual abuse, confirmed. This involves forcing or coercing someone into sexual activity against their will.This can result in various physical and psychological health consequences.

Example 1: A 25-year-old female presents to the emergency room after being sexually assaulted.Physical examination reveals evidence of trauma.The code T74.2 is used to document the sexual abuse., A 10-year-old male discloses during a therapy session that he has been repeatedly sexually abused by a family member. The therapist documents the confirmed abuse using T74.2., A 30-year-old male presents to his physician with long-term psychological issues stemming from childhood sexual abuse. The physician documents the history of abuse using code T74.2.

Documentation should include detailed information about the event, the extent and nature of any physical injuries, and psychological impact. Any available evidence, such as medical reports or police reports, should also be included.It's crucial to document the patient's account of the event in their own words whenever possible.

** Excludes1: abuse and maltreatment in pregnancy (O9A.3-, O9A.4-, O9A.5-) adult and child maltreatment, suspected (T76.-)

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