Primary Care Coding Alert

Reader Questions:

Follow This Guidance to Code Adverse COVID Vaccine Reaction

Published on Wed Dec 15, 2021

Question: We administered a COVID-19 vaccine to a patient and, as we usually do, we asked the patient to remain 15 minutes after the vaccination to monitor for any side effects. About 10 minutes after the vaccination, the patient reported experiencing chills and malaise, which are normal side effects for COVID vaccines. Should we code them, and as this is a COVID vaccine, is there a special way to document what happened?

AAPC Forum Participant

Answer: Coding for an encounter like this is pretty straightforward if you follow the recently issued guidance published in the AHA ICD-10-CM Coding Clinic. It instructs you “to report a code(s) for side effects when the patient requires additional treatment or medical care such as monitoring or treatment for the side effects” (2021 Vol. 8, No. 1).

So, in this case, as the side effects you describe are normal for COVID-19 vaccines, and assuming you provided additional treatment or monitoring for the side effects, the Coding Clinic tells you to “assign the code for the nature of the effect,” which in your case would be R68.83 (Chills (without fever)) and R53.81 (Other malaise). Then, also per the Coding Clinic, you’ll assign T50.B95A (Adverse effect of other viral vaccines, initial encounter) for the adverse reaction.