2025 ICD-10-CM code T76
Suspected adult and child abuse, neglect, and other maltreatment. Use additional code, if applicable, to identify any associated current injury.
Medical necessity for this code is established when the clinical findings and/or patient's report raise a reasonable suspicion of abuse, neglect, or maltreatment. This code is used for suspected cases, and further investigation is required for confirmation.
Clinicians are responsible for documenting the evidence and rationale for suspecting abuse, neglect, or maltreatment. If the abuse is confirmed, code T74 should be used instead.
In simple words: This code indicates a suspicion of abuse, neglect, or maltreatment of an adult or child. Further investigation is needed to confirm the suspicion.
Suspected adult and child abuse, neglect, and other maltreatment. Use additional code, if applicable, to identify any associated current injury. Excludes1: adult and child maltreatment, confirmed (T74.-) suspected abuse and maltreatment in pregnancy (O9A.3-, O9A.4-, O9A.5-) suspected adult physical abuse, ruled out (Z04.71) suspected adult sexual abuse, ruled out (Z04.41) suspected child physical abuse, ruled out (Z04.72) suspected child sexual abuse, ruled out (Z04.42)
Example 1: A child presents with multiple bruises in different stages of healing and the physician suspects physical abuse., An elderly patient is admitted with signs of dehydration and malnutrition, raising concerns about neglect., An adult patient reports experiencing emotional manipulation and control by their partner, leading to a suspicion of psychological maltreatment.
Thorough documentation of physical findings, behavioral observations, patient statements, and any other evidence that supports the suspicion of abuse, neglect, or maltreatment is crucial. Specific details about the nature and extent of the suspected maltreatment should be included.
** It's essential to differentiate between suspected and confirmed cases of abuse and neglect. Code T76 is specifically for suspected cases, while T74 is used for confirmed cases. Reporting requirements for suspected abuse and neglect vary by jurisdiction, and clinicians should be familiar with local regulations.
- Specialties:Pediatrics, Geriatrics, Family Medicine, Emergency Medicine, Social Work
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Emergency Room - Hospital, Home, Nursing Facility