Electronic Record Keeping in Human Trafficking Cases

Documenting Human Trafficking in Medical Records

In 2019 the CDC added new data collection fields including new “T codes” for reporting cases of suspected and confirmed forced labor and sexual exploitation (labor trafficking and sex trafficking) and new “Z codes” for the examination and observation of human trafficking victimization.

According to the Department of Health and Human Services, the ICD-10 codes are important to human trafficking because when these codes are added to a patient’s electronic health record, health care providers can use these codes to track and improve patient care. Providers can use a combination of ICD-10 codes to more fully show how trafficking affects physical and mental health. Altogether there are 16 new codes for suspected and confirmed cases of human trafficking. Some examples of the new T codes include:

  • T74.5 – Forced sexual exploitation, confirmed.
  • T74.51 – Adult forced sexual exploitation, confirmed.
  • T74.52 – Child sexual exploitation, confirmed.
  • T74.6 – Forced labor exploitation, confirmed.
  • T74.61 – Adult forced labor exploitation, confirmed.

The new Z codes include:

  • Z04.81 - Encounter for examination and observation of victim following forced sexual exploitation
  • Z04.82 - Encounter for examination and observation of victim following forced labor exploitation

Documenting Human Trafficking in Clinic Medical Records

It is important to be aware of some current challenges in documenting human trafficking in Electronic Health Records (EHR). Confidential patient information, including ICD codes for human trafficking, could threaten client privacy and safety. Providers who are not trained in human trafficking may unintentionally harm patients when they use a diagnostic code for trafficking but do not provide referrals and other important information to help the client. It is also critical to ensure that staff do not violate confidentiality of the client. Some experts recommend that providers record only medical information in the client record. Additional information such as the victim’s story, could be subpoenaed for use in the criminal justice system. Even though there are challenges, using ICD codes for trafficking is important because they can provide data to confirm the extent to which trafficking occurs in the U.S. Here are some ways health professionals and administrators can protect patient privacy and confidentiality:

  • Ensure that electronic health records are secure. If your Center does not already have them, create and enforce policies that protect data.
  • Train staff as to how to manage confidential information.
  • Train providers to communicate with clients about how and what information is recorded in the electronic health record.

Documenting Human Trafficking in Medical Records

The National Human Trafficking Training and Assistance Center (NHTTAC) suggests creating a plan for rolling out ICD-10 codes.

It includes training all providers and staff on labor and sex trafficking and how to respond to suspected trafficking, training all professionals who create or read medical records about confidentiality policies and practices, especially as it concerns human trafficking; and introducing all staff including clinicians, support staff, coders, on the new human trafficking ICD codes.

Clinicians must know how to inform patients about the confidentiality measures included in the electronic health record and how ICD codes are used.

In addition, health providers should implement a zero-tolerance policy for staff bias or discrimination against patients.

Remember: Using ICD-10 codes helps providers gain a full picture of the patient’s circumstances and respond to patients in a person-centered, trauma-informed, and multidisciplinary way.  In addition, using ICD-10 codes to track medical conditions related to trafficking can help track the nature and scope of human trafficking and this information can be used to create policies and to support better resource allocation.