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Question: Our practice has been administering COVID-19 vaccines to our patients who are of age to receive one. We know how to document the vaccine and the administration, but how do we document an adverse reaction to the vaccine?

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Answer: The AHA ICD-10-CM Coding Clinic gave the following advice in Vol. 8, No. 1 (2021) on how to code adverse reactions to the COVID-19 vaccine.

First, assign the code for the side effects: Depending on the patient, this could take the form of numerous conditions, such as R07.89 (Other chest pain), R09.89 (Other specified symptoms and signs involving the circulatory and respiratory systems), and R53.81 (Other malaise).

Then, assign the code for the reaction: Again, this will depend on the patient鈥檚 individual circumstances. For an adverse reaction, you鈥檒l use T50.B95A (Adverse effect of other viral vaccines, initial encounter). But if the patient goes into anaphylactic shock after receiving the vaccine, you鈥檒l use T80.52XA (Anaphylactic reaction due to vaccination, initial encounter).

Why? Even though the synonyms accompanying the T80.5- codes indicate that the codes should be used for anaphylactic shock after the patient had received a serum-based vaccine, and the COVID-19 vaccine is an mRNA vaccine and not serum-based, the Coding Clinic notes that 鈥渁lthough subcategory T80.5, identifies anaphylactic reaction to serum, it is the closest available code to capture this condition.鈥�

Expert coding tip: The Coding Clinic article notes that even if the side-effects are normal, 鈥渋t would be appropriate 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.鈥�