Z91.41Personal history of adult abuse

Z91.41 is the ICD-10-CM diagnosis code for personal history of adult abuse. It belongs to category Z91 (personal risk factors, not elsewhere classified), block Z77-Z99 (persons with potential health hazards related to family and personal history and certain conditions influencing health status) and chapter 21 (factors influencing health status and contact with health services). It is a header code, so it can't be reported by itself; one of its 6 subcodes must be used instead.

Within Z91.4 (personal history of psychological trauma, not elsewhere classified), Z91.41 is specifically for personal history of adult abuse. Related codes cover personal history of forced labor or sexual exploitation (Z91.42) and other personal history of psychological trauma, not elsewhere classified (Z91.49).

To report this condition, pick the subcode that matches the documentation: Z91.410 (abuse), Z91.411 (abuse), Z91.412 (neglect), Z91.413 (abuse), Z91.414 (abuse) and Z91.419 (abuse).

The conditions in its Excludes2 note aren't part of Z91.41, but may be coded alongside it if the patient has both: personal history of abuse in childhood (Z62.81-).

It has been part of ICD-10-CM since the code set took effect on October 1, 2015 and hasn't changed since.