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2025 ICD-10-CM code Y07.411

Sister, perpetrator of maltreatment and neglect.

Coding guidelines emphasize the importance of complete and accurate documentation to ensure proper coding.This includes specifying the type of maltreatment and any resulting injuries using appropriate codes from other chapters in the ICD-10-CM classification.

No modifiers apply directly to this diagnosis code.

The medical necessity for coding Y07.411 hinges on documented evidence of maltreatment and neglect. This requires clear clinical documentation, including a statement from the victim, physical or psychological evaluations, and evidence that the abuse is causing harm.

The clinical responsibility for coding this diagnosis would typically fall upon the healthcare professional directly involved in assessing and treating the victim of maltreatment and neglect.This may be a physician, nurse, social worker, or other healthcare professional depending on the setting and the nature of the treatment.

IMPORTANT:Related codes may include those specifying other family members as perpetrators of maltreatment and neglect (e.g., Y07.11 for biological father, Y07.12 for biological mother, Y07.410 for brother, etc.).Additional codes might be necessary to specify the type and nature of the maltreatment (e.g., codes from Chapter 19 for specific injuries).

In simple words: This code is used when a sister hurts or neglects someone in her care.It covers different types of harm, like physical or emotional abuse and neglect.

This ICD-10-CM code classifies instances where a sister is identified as the perpetrator of maltreatment and neglect against another individual.Maltreatment encompasses various forms of abuse, including physical, emotional, sexual, and neglect. Neglect can be physical, emotional, or educational in nature. This code is used to indicate the familial relationship between the perpetrator and the victim, adding specificity to the injury or adverse effect.

Example 1: A 10-year-old girl is admitted to the hospital with multiple bruises and a fractured arm, injuries consistent with physical abuse.The child discloses that her older sister is responsible for the injuries.Code Y07.411 would be assigned to document the sister's role as the perpetrator., A social worker assesses a family where a 16-year-old girl is neglecting her younger sister, leaving her unsupervised, leading to inadequate care and potential safety risks. Y07.411 could be used in conjunction with additional codes specifying the type of neglect., A psychiatrist evaluating a young adult reports evidence of long-term emotional abuse by her older sister, resulting in significant psychological trauma and the need for ongoing therapy.Code Y07.411 could be used, along with codes to specify the psychological impact.

Documentation should include details supporting the diagnosis, such as the victim's statement, physical examination findings (e.g., injuries), and any corroborating evidence from other sources (e.g., family members, witnesses, medical records). Detailed accounts of the neglect or maltreatment should be recorded.

** This code should always be used in conjunction with codes that describe the nature of the injury or condition resulting from the maltreatment.It's crucial to accurately document the type of abuse and its impact on the victim.

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