ICD-10-CM Code Z91.410

Personal history of adult physical and sexual abuse

Version 2020 Replaced Code Billable Code Adult Diagnoses Unacceptable Principal Diagnosis POA Exempt

Valid for Submission

Z91.410 is a billable code used to specify a medical diagnosis of personal history of adult physical and sexual abuse. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Z91.410 might also be used to specify conditions or terms like history of adulthood abuse, history of adulthood abuse, history of adulthood abuse, history of adulthood abuse, history of adulthood abuse, history of adulthood of physical abuse, etc The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

The code Z91.410 is applicable to adult patients aged 15 through 124 years inclusive. It is clinically and virtually impossible to use this code on a patient outside the stated age range.

ICD-10:Z91.410
Short Description:Personal history of adult physical and sexual abuse
Long Description:Personal history of adult physical and sexual abuse

Replaced Code

This code was replaced in the 2020 ICD-10 code set with the code(s) listed below. The National Center for Health Statistics (NCHS) has published an update to the ICD-10-CM diagnosis codes which became effective October 1, 2019. This code was replaced for the FY 2020 (October 1, 2019 - September 30, 2020).

  • Z91.42 - Personal history of forced labor or sexual exploitation

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code Z91.410:

Type 1 Excludes

Type 1 Excludes
A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code Z91.410 are found in the index:


Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:

  • Adult diagnoses - Adult. Age range is 15–124 years inclusive (e.g., senile delirium, mature cataract).
  • Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • History of adulthood abuse
  • History of adulthood abuse
  • History of adulthood abuse
  • History of adulthood abuse
  • History of adulthood abuse
  • History of adulthood of physical abuse
  • History of adulthood of sexual abuse
  • History of domestic abuse
  • History of domestic physical abuse
  • History of domestic sexual abuse
  • History of domestic violence
  • History of physical abuse
  • History of physical abuse
  • History of rape
  • History of sexual abuse
  • History of victim of elder physical abuse
  • History of victim of elder sexual abuse
  • History of victim of rape as an adult
  • Victim of sexual abuse

Present on Admission (POA)

Z91.410 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here .

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert Z91.410 to ICD-9

  • V15.41 - Hx of physical abuse (Approximate Flag)

Code Classification

  • Factors influencing health status and contact with health services (Z00–Z99)
    • Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)
      • Personal risk factors, not elsewhere classified (Z91)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


Sexual Assault

Sexual assault is any sexual activity to which you haven't freely given your consent. This includes completed or attempted sex acts that are against your will. Sometimes it can involve a victim who is unable to consent. It also includes abusive sexual contact. It can happen to men, women or children.

The attacker can be anyone - a current or former partner, a family member, a person in position of power or trust, a friend, an acquaintance, or a stranger.

Sexual assault can affect your health in many ways. It can lead to long-term health and emotional problems. It is important to seek help if you have been assaulted. First, get to a safe place. Then dial 9-1-1 or go to a hospital for medical care. You may want to have counseling to deal with your feelings. The most important thing to know is that the assault was not your fault.

Centers for Disease Control and Prevention


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