Wiki child Abuse sequela verses history of abuse

[snwhite0730]

I work at an IP mental health hospital and need some clarification on when and how to use the sequela code for abuse.

We had a patient who is an adult now but suffered sexual abuse as a child, he now has PTSD and other mental health dx from that abuse. Reading the guidelines it didn't seem appropriate to code adult abuse as this took place when he was a child and using history also didn't seem appropriate since he is currently in treatment directly related to the abuse he suffered as a child. I coded PTSD followed by the child abuse confirmed T74.22XS with the appropriate Y07 codes for the perpetrator. Our encoder gave an alert that based on the age of the patient the code wasn't valid but as stated above it didn't seem appropriate to use adult. The claim was denied by his insurance.

I submitted this scenario to AHA coding clinic who also stated that the code use is based on when the abuse took place regardless of the age of the patient. Our corporate RHIT has now escalated this since there are others stating it is better to use the history of abuse code to ensure payment from insurance. Is there anyone who can give a little more guidance on proper reporting using these codes? The 7th character sequelae seems more than appropriate in this case, it's the age of the code used that is making this harder to code and fight the insurance. Any help or guidance is greatly appreciated!

 

[thomas7331]

The guidelines aren't really very clear on this, but I would just remember that the ‘T’ codes chapter in ICD-10 are primarily used for reporting physical injuries. The guidelines state that '7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn'. So sequelae would be physical conditions that are associated with the injury itself after the initial injury has healed, not the psychological effects associated with the experience of the abuse. For example, you might use this code if the physician documented scarring from injuries that had occurred as a result of abuse. In this scenario, I would code the history of abuse and not use the ‘T’ code since you are not reporting after effects of a physical injury. I would consider PTSD to be a condition that is associated with abuse but not 'a direct result' of it since it was not necessarily directly caused by the injuries, if there were any.

 

[snwhite0730]

Thank you for the reply. Your explanation makes a lot of sense, but the guidelines also state to code the abuse, neglect and maltreatment followed by any accompanying mental health OR injury codes. The PTSD is a mental health injury that is related to the abuse and would fall into a sequelae since it ' formed' as a direct result of his abuse, the same way a scar would form from a burn right? This is the part that I get 'stuck' on.

 

[sls314]

Thank you for the reply. Your explanation makes a lot of sense, but the guidelines also state to code the abuse, neglect and maltreatment followed by any accompanying mental health OR injury codes. The PTSD is a mental health injury that is related to the abuse and would fall into a sequelae since it ' formed' as a direct result of his abuse, the same way a scar would form from a burn right? This is the part that I get 'stuck' on.

I'd be inclined to agree with you that the sequelae code is technically the correct code. Especially since you confirmed it with AHA coding clinic.

Sometimes payers request other codes that are similar due to whatever policies or system limitations the payer has. It's definitely frustrating when you know what the "right" code is.

(I have this come up often myself in my specialty - there's a code that should be for technical services only, but my state's Medicaid and Aetna both use it for professional services. Grinds my gears every time I have to use it for physician services, but for now its what has to be done until the specialty society influences the payers to adapt to the better code.)

In this case, since the payer wants the PTSD with the history of child sexual abuse code, that may be what you have to use. It's not a completely inaccurate representation of what happened to the patient, even though we know as coders that the sequalae code may be "more right."