Adult sexual abuse, confirmed, initial encounter

This code signifies a confirmed instance of sexual abuse experienced by an adult patient. It indicates that the abuse has been substantiated through clinical assessment or other reliable means, and this is the first time the patient is being seen for this specific issue.

Apply this code when documenting the initial encounter for an adult patient presenting with confirmed sexual abuse. This includes situations where the patient discloses the abuse, or when evidence of sexual abuse is identified during a clinical examination or investigation.

• Ensure documentation clearly states the patient is an adult and the sexual abuse is confirmed.
• Reserve this code for the initial visit related to the confirmed abuse; subsequent encounters will require a different seventh character.
• Always sequence this code as a primary diagnosis when it is the reason for the encounter, or as a secondary diagnosis if it is an underlying factor impacting the primary reason for the visit.