CHILD ATHLETE ABUSE ORBITAL FLOOR FRACTURE ICD-9 CODE

USE OF ICD-9 CODE EXAMPLE

If the Coach strikes a Child Athlete in the left eye with his fist during sport participation and fractures the left orbaital floor. The Medical Erergency Department Chart is tendered with:
• Impression (Initial Diagnosis):
1. Left Orbital Floor Fractures
2. Child Physical Abuse (CPA)

The Insurance Claim to 3rd Party Payor or Medical Insurance is billed with the following codes:
• ICD-9 Code – Fractures
1. Closed fracture of orbital floor (blow out) Diagnosis Code 802.6
2. 2. ICD-9 Code - Modifiers

• ICD-9 Code for Child Physical Abuse (CPA)
1. T74.12 Child Physical Abuse Confirmed
2. YO7 The Child Abuse Perpetrator is Known and is the Coach

Disposition recorded in ED Medical Record:
• Admit to Hospital
• Call OR / Schedule Surgery
• Additional Lab Work
• File Report > Authorities for CPA

PHYSICIAN USE OF DIAGNOSIC CODES FOR CHILD AND ADULT ABUSE

[Physician Use Of Diagnostic Codes For Child and Adult Abuse,\
J Am Med Womens Assoc. 2000 Summer; 55 (4):243.]
Diagnostic codes for abuse are not often used. Because these codes represent an important tool for reporting the prevalence and incidence of abuse, such documentation could lead to greater support for health care policies and resource allocation for victims of abuse. Lack of awareness about the diagnostic codes for abuse may be one explanation for underuse, but other barriers are also discussed.
In this study, only 93 diagnoses of child or adult abuse were coded for 351,359 patient visits during the four years. As we would expect, child abuse was diagnosed more often than adult abuse (67 v 26), and the majority of cases (n = 57) were visits to emergency departments.
[ADVANCE, ICD-10 TRANSITION TIPS AND TOOLS
How ICD-10 Differs From ICD-9-CM, Part 9, By Carol Spencer, RHIA, CCS, CHDA, Dec 6, 2010]
‘Adult and Child Abuse, Neglect, and Other Maltreatment provides guidance to sequence of first the appropriate code from categories T74.- or T76.- for abuse, neglect, and other maltreatment, followed by an accompanying mental health or injury code(s).’
“If the documentation in the medical record states abuse or neglect, it is coded as confirmed. It is coded as suspected if it is documented as suspected.”
“For cases of confirmed abuse or neglect, an external cause code from the assault section (X92-Y08) should be added to identify the cause of any physician injuries.
“Add a perpetrator code (Y07) when the abuser is known. If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter, use code Z04.71, suspected adult physician and sexual abuse, ruled out, or code Z04.72, suspected child physical and sexual abuse, ruled out. Do not use code from T76.
“If the external cause is included in the complication-of-care codes, the code includes the nature of the complication as well as the type of procedure that caused it. For this reason, no external cause code indicating the type of procedure is necessary. If the complication-of-care codes within the body system chapter are specific to its organs and structures, sequence these codes first followed by a code(s) for the specific complications, if applicable.”

_________________________________________
ICD-10-CM (2010)/CHAPTER 19/T66-T78
T74 Adult and child abuse, neglect and other maltreatment, confirmed
Excludes1: abuse and maltreatment in pregnancy (O94.3-O94.5-)
adult and child maltreatment, suspected (T76.-)
Use additional code, if applicable, to identify any associated current injury
Use additional external cause code to identify perpetrator, if known (Y07.-)
The appropriate 7th character is to be added to each code from category T74
A initial encounter
D subsequent encounter
S sequela
T74.0 Neglect or abandonment, confirmed
T74.01 Adult neglect or abandonment, confirmed
T74.02 Child neglect or abandonment, confirmed
T74.1 Physical abuse, confirmed
Excludes2: sexual abuse (T74.2-)
T74.11 Adult physical abuse, confirmed
T74.12 Child physical abuse, confirmed
Excludes2: shaken infant syndrome (T74.4)
T74.2 Sexual abuse, confirmed
Rape, confirmed
Sexual assault, confirmed
T74.21 Adult sexual abuse, confirmed
T74.22 Child sexual abuse, confirmed
T74.3 Psychological abuse, confirmed
T74.31 Adult psychological abuse, confirmed
T74.32 Child psychological abuse, confirmed
T74.4 Shaken infant syndrome
T74.9 Unspecified maltreatment, confirmed
T74.91 Unspecified adult maltreatment, confirmed
T74.92 Unspecified child maltreatment, confirmed

____________________________________

V-CODES
ABUSE
DSM-IV-TR Diagnostic Codes:
V61.21 Physical Abuse of Child
V61.21 Sexual Abuse of Child
V61.21 Neglect of Child
V61.1 Physical Abuse of Adult
V61.1 Sexual Abuse of Adult

DSM-IV-TR Diagnostic Codes:
V61.9 Relational Problem Related to a Mental Disorder or
General Medical Condition
V61.20 Parent-Child Relational Problem
V61.10 Partner Relational Problem
V61.8 Sibling Relational Problem
V61.81 Relational Problem Not Otherwise Specified

The above diagnostic codes will be used when the focus of service and/or clinical attention is the
perpetration of child or adult abuse and/or neglect not due to a mental disorder. The above codes
should be used as the primary diagnosis, coded on Axis I, when the participant can be
effectively treated using brief, problem solving therapy. Safety of the abused party should be the
first focus of any intervention.
The following guidelines are to be considered and rendered within the context of the
participant’s cultural, ethnic, and spiritual values in order to maximize the accuracy of the
diagnosis, the effectiveness of the treatment/intervention, and the best possible outcomes for the
participant and the family.
Diagnostic Guidelines:
1. These guidelines should be applied if the focus of the intervention/treatment is the
perpetrator of the abuse. If the participant is the victim of the abuse then the diagnostic
determination should be made as defined in the DSM-IV-TR, and coded as 995.5 for a child
or 995.81 for an adult.
2. Establish diagnostic accuracy as defined in DSM-IV-TR. The distinguishing feature of this
V-code is that the “focus of clinical attention is severe mistreatment of one individual by
another through physical abuse, sexual abuse, or child neglect.” . It is imperative that a
primary mental health diagnosis be ruled out, especially personality and substance related
disorders. Typically, this V-code category is time limited in terms of treatment. If more
acute treatment is needed, there is probably a primary mental health diagnosis that is not
clearly evident.
Assessment should include probing for symptoms associated with problems in relationships,
substance abuse and personality disorders. A comprehensive history of the participant
should be obtained as part of the assessment and should include history of previous
relationships, prior interventions concerning relationships, history and treatment history of
substance use and abuse as well as current medical and work problems.
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3. It may be necessary under Federal and State Regulations to report suspected abuse or neglect
to the appropriate authorities.
4. In the diagnostic formulation, consider the following behaviors or symptoms:
a. Child abuse and neglect may include, but are not limited to:
• Consistent and/or frequent conflict between parent and child
• Parental incompetence
• Lack of parental control in the home
• Poor parent-child communication
• Inappropriate use of discipline / heavy discipline or over-punishment
• Unrealistic expectations of child’s behavior
• Reports of truancy on the part of the child
• Parent overprotective of child
• Parental isolation of child
• Reports/descriptions of physical/sexual abuse by the parent or other adult (hitting,
kicking, slapping, torture or sexual activity)
• Reports/descriptions of emotional and verbal abuse including: withdrawal of
affection and humiliation
• Failure to provide a nurturing and safe living environment
• Misappropriation of the minor’s trust-funds; earnings or other financial
assets/properties via coercion and or manipulation.
b. Adult abuse (neglect):
• Consistent and/or frequent conflicts between client and another adult
• Reported efforts to maintain control of the other adult
• Poor communication between parties
• Inappropriate use of discipline in an adult relationship
• Unable to establish appropriate boundaries
• Overprotective of other adult
• Isolation of the other adult
• Reports/descriptions of physical/sexual abuse (hitting, kicking, slapping, torture
or unwanted sexual activity including sexual coercion or rape)
• Reports/descriptions of emotional and verbal abuse including withdrawal of
affection and humiliation
• Caregiver neglect including failure to provide necessary skilled nursing
assistance, proper nutrition, access to support for activities of daily living
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• Censoring/Editing of the Elder’s incoming or outgoing US Mail; telephone calls
or other electronic media.
• Misappropriation of the elder’s financial assets and/or properties via coercion;
manipulation or fraudulent actions.
c. Other behaviors or symptoms to consider:
• Anxiety/paranoia related to the relationship
• Symptoms or behaviors exacerbated by the use of substances
• Identified stalking behaviors including unwanted visits to another’s work location
• Difficulty concentrating at work due to focus on the victim of the abuse
• Negative relationships with co-workers or supervisors
• Legal problems related to behaviors toward family members
d. All five Axes should be part of the diagnostic assessment and attention paid to issues
of safety of the victim and others around the victim as well as the availability of
appropriate support systems.
Treatment Guidelines:
1. Goal of treatment should include the elimination of the abusive behaviors and the
establishment of more appropriate ways of relating to others. Note: It is critical that treating
clinicians focus particularly on engaging victims of abuse and neglect and motivating them
to follow through with treatment recommendations as well as educating first time users
regarding expectations of counseling services.
2. The individual should be given support to identify those behaviors which are abusive in
nature:
• Parenting techniques – physical and verbally abusive punishments
• Ways of communicating – verbal violence and degrading interactions
• Anger response – appropriate to the situation and controlled
3. The treatment should include the development of awareness of internal triggers for abusive
behavior.
4. Identification of coping and management techniques to reduce/eliminate abusive responses:
• Time out – cool down techniques
• Alternative behaviors
• Visualization of alternative methods of addressing an abuse generating situation
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5. Treatment should include strategies for victims of abuse to draw comfort and support from
healthy and positive relationships at work and involvement in community activities.
6. Therapeutic Modalities can include:
A. Individual Therapy
• Focused substance abuse treatment, as appropriate
• Behavior modification and anger management
B. Group Therapy
• Focused therapy for abusers stressing anger management
• Parent Effectiveness Training
• Care for the caregiver
C. Family Interventions
• Referrals to community based services for families in crisis
• Referrals to child or adult protective services
• Where appropriate family therapy focused on restructuring family interactions
D. Community Based Programs
• Self-Help groups such as Alanon and Alateen, and self-help for substance abusers
• Churches/Synagogues/Mosques with programs for families in crisis
• Respite Care for caregivers
• Visiting Nurses Association
• Adult/Child Day Care services
References:
American Psychiatric Association, May, 1994, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, American Psychiatric Association, Washington, DC.
James M. Oher, Daniel J. Conti, Arthur E. Jongsma, Jr., 1998, The Employee Assistance
Treatment Planner, John Wiley & Sons, Inc. New York.