AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 2; Ask The Editor

Non-Accidental Trauma and Suspected Child Abuse

A 3-year-old child presents to the Emergency Department (ED) due to trauma. After work-up, an injury pattern including diffuse bruising, cephalohematoma and Glasgow coma score (GCS) 3T with no movement response to pain, cough, gag, corneal or spontaneous breathing were noted. The child is subsequently admitted to the pediatric intensive care unit (PICU) due to severe traumatic brain injury and cardiac arrest. The trauma team documented, “injury pattern highly suspicious for non-accidental trauma (NAT).” There does not appear to be an ICD-10-CM code to capture non-accidental trauma. How should this diagnosis be reported? ...

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