Pulmonology Coding Alert

Question: During routine evaluation and management (E/M) visits, providers in our practice have asked patients about the patients’ COVID-19 vaccination status. Several patients have attested to either not being fully vaccinated or are not vaccinated at all for one reason or another.

Is there a way to document if a patient is unvaccinated or not completely vaccinated against COVID-19?

Michigan Subscriber

Answer: Yes, as of April 1, 2022, you can correctly document a patient’s COVID-19 vaccination status with ICD-10-CM code options under the Z28.3- (Underimmunization status) subcategory.

The code category requires 5th and 6th characters to complete the codes. You’ll assign Z28.310 (Unvaccinated for COVID-19) for patients who have not received any vaccinations against COVID-19. You’ll assign Z28.311 (Partially vaccinated for COVID-19) for patients who haven’t completed the vaccination series or haven’t received the booster shots. According to the ICD-10-CM Official Guidelines, section I.C.1.g.1.n, Z28.311 “may be assigned when the patient has been partially vaccinated for COVID-19 as per the recommendations of the Centers for Disease Control and Prevention (CDC) in place at the time of the encounter.”

You’ll use Z28.39 (Other underimmunization status) to indicate other reasons as to why the patient isn’t fully vaccinated against COVID-19. Additional terms listed under Z28.39 include “Delinquent immunization status” and “Lapsed immunization schedule status.”

A note listed above Z28.310 instructs you not to use these codes for patients who aren’t yet eligible for the vaccines, as determined by their healthcare provider.

Code Z28.3- also features a Use additional code note instructing you to choose from the following codes or expanded codes, if they’re applicable to the patient’s vaccination status:

• Z28.0- (Immunization not carried out because of contraindication)
• Z28.1 (Immunization not carried out because of patient decision for reasons of belief or group pressure)
• Z28.2- (Immunization not carried out because of patient decision for other and unspecified reason)
• Z28.8- (Immunization not carried out for other reason)

​These codes and code subcategories allow you to document if the patient provides a specific or an unspecific reason for not receiving the vaccination or not completing the vaccination series.