We are looking for clarification regarding what is considered abuse. I understand, for example, a parent assaulting a child, a spouse/significant other assaulting a spouse, an adult child assaulting an elderly parent is abuse,, but is any physical assault considered abuse for the first registry question “was patient being evaluated for abuse?” or are there specific criteria that constitutes abuse? For example, an acquaintance or neighbor as a one-time event assaulting the patient, how would we answer that first registry question? Or a guy is sitting at a bar and someone comes up and hits him?
Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well.
Any physical assault is not abuse. However, according to ICD-10-CM coding guidelines, adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. Lastly, if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.
Regardless of an assault or abuse as the presenting injury, you will answer the element “was the patient being evaluated for abuse as “yes” as long as the patient has a workup for physical or sexual abuse at your facility due to the presenting injury event. To code mechanism of injury correctly when abuse is suspected or confirmed, you will need to follow the guidelines in the reference document mentioned above and the current PTOS Manual.
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