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v1.0.0
ICD-10 Guide
DiagnosesAssault By Person

Assault By Person

ICD-10 Coding for Assault by Person(T74.11XA, Y04.0XXA)

PRIMARY SPECIALTYEmergency Medicine
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Assault By Person?
Essential facts and insights about Assault by Person

Key Clinical Considerations:

  • Presence of physical injuries or psychological trauma resulting from an assault by another person.
  • Laboratory findings may include toxicology screens if substance use is suspected.
  • Physical examination findings may include bruising, lacerations, fractures, or signs of psychological distress.
  • Imaging may be required to assess for internal injuries or fractures resulting from the assault.
  • Severity criteria may include the extent of injuries (e.g., minor vs. life-threatening) and the need for surgical intervention.

Clinical Information

Clinical Criteria & Documentation Requirements

  • Medical records must document the mechanism of injury, including details of the assault.
  • Specific terminology such as 'assault', 'physical injury', and 'psychological trauma' must be used.
  • Examples include documenting the type of injuries sustained and the circumstances of the assault.
  • Medical necessity must be established through documentation of the need for treatment related to the assault.
  • Quality measures may include documentation of follow-up care and mental health assessments.

Coding Guidelines

Usage Guidelines & Examples

  • Use T74.11XA for initial encounter of assault-related injuries; Y04.0XXA for external cause coding.
  • Do not use these codes for self-inflicted injuries or injuries resulting from accidents.
  • Similar codes include T74.12XA for sexual assault and T74.13XA for assault by a known person.
  • Common errors include misclassifying the cause of injury or failing to document the assault mechanism.
  • In complex cases, ensure to capture both the injury and the cause accurately to avoid denials.

Code Exclusions

Important Exclusions

  • Excludes self-inflicted injuries (e.g., suicide attempts) and injuries from accidents.
  • Alternative codes for excluded conditions include those for accidental injuries or self-harm.
  • Conditions are excluded to ensure accurate representation of the cause of injury.
  • Common mistakes include misclassifying self-harm as assault or failing to document the assault mechanism.
  • Related but distinct conditions include domestic violence and bullying, which may require different coding.

Related ICD-10 Codes

Primary Codes
T74.11XA
Assault by person, initial encounter
Y04.0XXA
Assault by unspecified person, initial encounter
Ancillary Codes
Y07.-
Differential Codes
Z04.71
X93.0XXA

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Emergency Medicine

Specialty Applications

  • Applies to patients with injuries resulting from physical assaults.
  • Patient populations include all ages, with particular attention to vulnerable groups.
  • Clinical settings include emergency departments, urgent care, and inpatient facilities.
  • Specialty-specific applications may involve emergency medicine, psychiatry, and trauma surgery.
  • Treatment contexts include immediate care for physical injuries and psychological support.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Template: 'Patient diagnosed with assault-related injuries based on physical examination findings.'

Template 2

Template: 'Clinical presentation consistent with assault including bruising and psychological distress.'

Template 3

Template: 'Diagnostic criteria for assault met as evidenced by documented injuries and mechanism of injury.'

Template 4

Template: 'Treatment plan initiated for assault-related injuries with wound care and psychological support.'

Template 5

Template: 'Follow-up care for assault-related injuries including monitoring for PTSD symptoms.'

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What documentation is required for this diagnosis?

Documentation must include details of the assault, injuries sustained, and treatment provided.

How does this differ from similar diagnoses?

Key differences include the mechanism of injury and the context of the assault.

What are common billing considerations?

Ensure accurate coding to reflect the nature of the assault for appropriate reimbursement.

What procedures are typically associated?

Common procedures may include wound care, imaging studies, and mental health evaluations.

Are there any quality reporting implications?

Quality measures may include tracking follow-up care and mental health assessments post-assault.