Z04.41 Encounter for examination and observation following alleged adult rape

The ICD-10-CM code for Encounter for examination and observation following alleged adult rape is Z04.41 (FY2026). It is a billable, claim-ready diagnosis code.

Classification

Chapter

21: Factors influencing health status and contact with health services (Z00-Z99)

Section

Z00-Z13: Persons encountering health services for examinations (Z00-Z13)

Category Z04

16 codes (12 billable)

FY2026 Status

Stable since FY2024

Also Known As

ICD-10-CM Alphabetic Index entries that lead to Z04.41:

• Rape › alleged, observation or examination, ruled out › adult
• Examination (for) (following) (general) (of) (routine) › alleged rape or sexual assault (victim), ruled out › adult
• Observation (following) (for) (without need for further medical care) › alleged rape or sexual assault (victim), ruled out › adult

Inclusion Terms

• Suspected adult rape, ruled out
• Suspected adult sexual abuse, ruled out

U.S. Hospital Utilization

• An estimated 120 U.S. inpatient stays in 2023 included Z04.41 among the documented diagnoses.

Source: National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, 2016–2023. National survey-weighted estimates.

Official Coding Guidelines

Suspected rape/sexual abuse ruled out: use Z04.41/Z04.42, not T76

If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged adult rape or code Z04.42, Encounter for examination and observation following alleged child rape, should be used, not a code from T76.

Used with any code in range A00.0-T88.9, Z00-Z99

1) Used with any code in the range of A00.0-T88.9, Z00-Z99 An external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that represents a health condition due to an external cause. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity.

Source: CMS — ICD-10-CM Official Guidelines for Coding and Reporting, FY2026

References

• CMS — ICD-10-CM Official Code Set and Guidelines, FY2026
• CDC/NCHS — ICD-10-CM Files and Browser Tool
• AHRQ — HCUP National Inpatient Sample, Frequencies by Diagnosis Code (2016–2023)