Child physical abuse, suspected, initial encounter

This code signifies a healthcare encounter where there is a suspicion of physical abuse inflicted upon a child. It is used when the clinician identifies signs or symptoms that raise concern for physical abuse, but a definitive diagnosis has not yet been established. This code captures the initial assessment and investigation of such concerns.

Apply this code when a child presents with injuries, behavioral changes, or other findings that prompt the healthcare provider to suspect physical abuse. This includes situations where the history provided is inconsistent with the observed injuries, or when there are multiple injuries in various stages of healing. It is appropriate for the very first visit related to these suspected findings.

• Always sequence this code as the primary diagnosis when the reason for the encounter is the suspected abuse.
• Do not use this code if physical abuse has been confirmed; instead, use the appropriate confirmed abuse code.
• Ensure supporting documentation clearly outlines the clinical indicators leading to the suspicion of child physical abuse.