Step 5: Documentation, Coding & Privacy Practices
Privacy of medical records is paramount when documenting and coding IPV. For survivors, this is not just a matter of privacy—it is a matter of safety. Electronic medical records and data sharing practices must be structured to keep survivors in control of their own health information.
These steps become even more critical as identification and documentation of IPV increases, patients receive expanded access to their own health information, and coordinated care is broadened to include services that address social determinants of health. Health systems and providers should review these principles and apply them to documentation and coding in the medical record.
Documentation and Coding
Coding protocols are critical for metrics and success monitoring. There are an array of codes to capture the IPV workflow.
Implementation Tip: Start with the IPV Coding Overview to begin your implementation.
- IPV Screening: Use validated CPT/LOINC codes for IPV education and screening encounters. Confirm codes are activated in provider-facing EHR templates and mappable to claims submitted to the MCP. See appendix for full list of CPT/LOINC and ICD-10 codes.
- IPV Disclosure: Use ICD-10 codes for documented IPV exposure and encounter. Validate code activation with your EHR partner before launch.
- Provider Charting and Documentation: Develop guardrails for appropriate documentation in progress notes and charting. Embrace the minimum necessary rule: If a patient discloses IPV, do not document personal perspective (e.g., “patient claimed partner hurt her.”) Simply indicate a positive disclosure, health impact, and steps taken.
Intimate Partner Violence Coding Summary
See the tables below for sample codes. View the full list of Diagnosis & Assessment codes(opens in new tab), and intervention codes(opens in new tab) in the appendix.
LONIC Assessment Codes
| LOINC 911221000124107 | Pre-Screen: CUES Implementation |
| LOINC 76499-3 | HARK: Humiliation, Afraid, Rape, and Kick Questionnaire |
| LOINC 93025-5 | PRAPARE (includes an optional set of IPV questions) |
ICD-10 Codes: Abuse Diagnosis Codes
| T76.11XA | Adult physical abuse, suspected, initial encounter |
| T74.11XA | Adult physical abuse, confirmed, initial encounter |
| T76.31XA | Adult psychological abuse, suspected, initial encounter |
| T74.31XA | Adult psychological abuse, confirmed, initial encounter |
| T76.21XA | Adult sexual abuse, suspected, initial encounter |
| T74.21XA | Adult sexual abuse, confirmed, initial encounter |
ICD-10 Codes: Factors Influencing Health Status
| Z91.414 | Adult Intimate Partner Violence |
| Z63.0 | Problems in relationship with spouse or partner |
| Z91.410 | Personal history of adult physical and sexual abuse |
| Z69.11 | Encounter for mental health services for victim of spousal or partner abuse |
| Z69.12 | Encounter for mental health services for perpetrator of spousal or partner abuse |
| Y07.03 | Male partner, perpetrator of maltreatment and neglect |
| Y07.04 | Female partner, perpetrator of maltreatment and neglect |
| Y07.05 | Non-binary, perpetrator of maltreatment and neglect |
| Y07.05 | Gender non-conforming, perpetrator of maltreatment and neglect |
SNOMED Codes
| 464011000124107 | Referral to care manager (procedure) |
| 464131000124100 | Referral to community health worker (procedure) |
| 464161000124109 | Referral to community resource network program (procedure) |
| 464291000124105 | Education about community resource network program (procedure) |
| 471091000124105 | Referral to Emergency Shelter Program (procedure) |
| 621321000124105 | Referral to victim assistance program (procedure) |
| 621341000124103 | Referral to National Domestic Violence Hotline (procedure) |
| 661561000124101 | Education about victim assistance program (procedure) |
| 661571000124108 | Education about victim advocate program (procedure) |
| 662931000124109 | Referral to intimate partner violence service (procedure) |
CPT Codes
| 96156 | Health behavior assessment or re-assessment (e.g., health-focused clinical interview, behavioral observations, clinical decision making) |
| 96160 | Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument |
| 96161 | Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument |
DHCS Policy Alignment
MCPs are required to implement documentation and data sharing practices that protect IPV survivors from inadvertent disclosure. This includes EOB suppression for IPV-related services and compliance with the California Address Confidentiality Program (ACP). Policies must be reviewed by legal and compliance before implementation.
DHCS PHM Guidance | CMIA | Evidence Code §1037 | W&I Code §18291
Survivor Voice – Confidentiality and Privacy
“How do we protect information when someone comes into our hospital and they have IPV concerns? Or, even if they’re not coming in with IPV concerns, they’re coming in with a medical concern, and then it’s discovered that IPV might be happening in their life? EMRs are not perfect, and my hospital’s done a really great job at trying to suppress some information. But I always challenge health plans to think about EOB suppression for those who may be identified as being in an IPV situation. Especially if I’m someone that’s on my abuser’s insurance. Being able to prepare information to let them know their privacy is just as important as anyone else’s is always super important.”
Privacy Practices
As you establish the coding procedures, the privacy protocols are essential for enhancing safety by minimizing unintended disclosures. Ensure the following areas are addressed in the MCP operations:
- How is IPV documented in the Electronic Health Record System (EHR)?
- Who has access to the health data?
- Where and when is health-related data de-identified?
- How are survivor communication preferences documented and tracked for compliance?
- How are communications and records shared only with the patient and not the policy holder?
Resources: Quick Links for Privacy Practices Guidance
Evidence-based training is key for provider success. Start here to begin building your training library:
EOB Suppression
Sensitive information suppression is critical to protect survivor information and unintended disclosures. Implement suppression protocols for sensitive services to prevent inadvertent disclosure to shared insurance holders. Then, set up a quarterly audit of claims for IPV-related disclosures in the EOB. The below figures provide guidance for survivor-centered EOB-suppression. MCPs may also reference EOB-suppression protocols currently in place through the Children and Youth Behavioral Health Initiative (CYBHI), in which all services rendered for children ages 17 and under are automatically suppressed.1
- California DHCS. Children and Youth Behavioral Health Initiative (CYBHI) Fee Schedule Program Manual.(opens in new tab) Guidance for Managed Care Plans and Insurers ↩︎