Question Spousal abuse coding. When is it considered confirmed or suspected?


Best answers
Hello! I bill for Inpatient hospital visits for teaching physicians. I don't normally see abuse charges come in so I am a little bit confused about how I should code this patient's situation.

The patient came in with heroin overdose. When asked the, patient stated his wife gave him the medication but he had never done any street drugs before. He states that his wife is trying to kill/hurt him and he doesn't want to go home. The patient was found to not have the mental capacity for medical decision making. But later was found to regained his mental capacities. The patient's children say that the wife is in fact trying to hurt the patient. He was discharged home to his daughter's home.

I was planning on coding this encounter with these codes:
T40.1X3A Poisoning by heroin, assault, initial encounter
T74.11 Adult physical abuse, confirmed
Y07.02 Wife, perpetrator of maltreatment and neglect

Would this be the correct codes for this scenario? I think what is tripping me up is that the provider does not say "Confirmed or Suspected." Does the patient's and his children's statements count as "confirmed abuse"?