Pulmonology Coding Alert

Question: If a patient presents to the emergency department after complaining of hives and swelling, severe breathing difficulties, and swelling in the throat after receiving the COVID-19 vaccine, how will I report the symptoms? Are there specific codes to report symptoms related to the COVID-19 vaccine, or should I document the symptoms with existing ICD-10-CM codes?

Florida Subscriber

Answer: For this scenario, you can assign code T80.52XA (Anaphylactic reaction due to vaccination, initial encounter) to document an anaphylactic reaction to the COVID-19 vaccine (91300-91304 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, …). Please note that while the T80.5 subcategory identifies anaphylactic reaction to serum and the COVID-19 vaccine is not serum based, it’s the closest available code to document the condition.

If you have a patient who is experiencing an anaphylactic reaction or other adverse reactions to the COVID-19 vaccine, you can report the corresponding ICD-10-CM code(s) for reactions that require additional treatment or medical care, such as treatment for the side effects, or monitoring.

For example, when a patient presents mild symptoms, such as malaise, you will assign code R53.81 (Other malaise) to document the symptom. You will also follow the symptom code with T50.B95A (Adverse effect of other viral vaccines, initial encounter).