Health Information Management

When good vaccines lead to bad reactions

HIM-HIPAA Insider, October 13, 2014

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With flu season just around the corner (hey, where did summer go?), Melissa took her 4-year-old son Andrew to Dr. Spock, the pediatrician, for his flu shot Wednesday.
 
With a minimum of fuss (and a small bribe by mom), Andrew took his shot and headed home with Melissa.
How would we code this visit in ICD-10-CM? From a diagnosis coding standpoint, it’s pretty easy. If you look up Vaccination in the ICD-10-CM Alphabetic Index, you’re directed to code Z23 (encounter for immunization).
 
We do need to pay attention to two notes with this code. First, ICD-10-CM instructs us to code for any routine childhood examination. In Andrew’s case, he was just visiting for a flu shot, so no routine exam. If he had gone in for a yearly physical or another problem and just happened to get his flu shot at the same time, we would code the vaccination second.
 
The other thing to note is Z23 is a very general diagnosis code. We don’t have codes for the specific vaccination. Instead, we need to report the vaccine using a HCPCS code for the drug and a CPT® code (in the outpatient setting) for the actual administration. ICD-10-CM includes a note in the Tabular List stating, “Procedure codes are required to identify the types of immunizations given.”
 
Andrew weathered his vaccine administration fine, but when it comes to the actual vaccine, things didn’t go as well. When Melissa was getting Andrew ready for preschool Friday, she noticed the injection site was red, inflamed, and hot to the touch. Andrew also reported it was a little itchy.
 
Back to Dr. Spock they go. Dr. Spock allayed Melissa’s fears of cellulitis and diagnosed an adverse reaction to the vaccine.
 
What would we code for this visit? Instead of heading to the Alphabetic Index (although we could do that if we wanted to), we’re going to the Table of Drugs and Chemicals. The table is located in the front of the ICD-10-CM Manual, just like it is in the ICD-9-CM Manual and the tables work pretty much the same way.
 
In the ICD-10-CM Table of Drugs, we find the following headings:
  • Poisoning, accidental (unintentional)
  • Poisoning, intentional self-harm
  • Poisoning, assault
  • Poisoning, undetermined
  • Adverse effect
  • Underdosing
The headers in ICD-10-CM differ from those in ICD-9-CM. For example, in ICD-9-CM, any poisoning that was intentional is classified as a suicide attempt. In ICD-10-CM, that category becomes poisoning, intentional, self-harm, which is a little more generic. Some people may intentionally poison themselves with a specific drug, but they are not attempting suicide.
 
You’ll also notice that the codes now start with T.
 
Underdosing is a new concept in ICD-10-CM, but it doesn’t really relate to Andrew’s vaccine reaction.
In ICD-9-CM, we don’t have a specific heading for an adverse effect. We use the therapeutic use column, which is a little ambiguous.
 
However, we know that Andrew suffered an adverse effect from the vaccine, so we would use a code from that column. But which code?
 
We can find it two ways. First, you can look up “influenza vaccine” and lo and behold, there’s the code. Or you can look up “vaccine,” then scroll through the list to find influenza. Either way you still end up with ICD-10-CM code T50.B95 (adverse effect of other viral vaccines).
 
Because we know not to code from the Alphabetic Index alone, we check the Tabular List to make sure we have all of the characters we need and that the code actually matches the diagnosis.
 
We have the correct code, but if you flip all the way back to the start of the T50 series of codes, you’ll see a notation that a seventh character is required for all of the T50 codes. Since this is Andrew’s first visit for his adverse reaction to the flu vaccine, we would use seventh character A. The correct code is T50.B95A.
Without the A, the code is invalid and you won’t get paid.
 
However, we’re not done coding just yet. If you look at the very beginning of the Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances (T36-T50) category, you’ll see several more notes, including:
 
Code first, for adverse effects, the nature of the adverse effect, such as:
  • Adverse effect NOS (T88.7 )
  • Aspirin gastritis (K29.-)
  • Blood disorders (D56-D76 )
  • Contact dermatitis (L23-L25 )
  • Dermatitis due to substances taken internally (L27.-)
  • Nephropathy (N14.0-N14.2)
What adverse effects did Andrew suffer? We know he had a rash and pain. If we look up rash, we find a code for rash following immunization:
  • T88.1, other complications following immunization, not elsewhere classified
    • Generalized vaccinia
    • Rash following immunization
Again we need our seventh character for the encounter, but we also need two placeholder Xs. Our final code is T88.1XXA.
 
The itch is a symptom that rolls into the rash code, so we don’t need to code it separately.
 
Fortunately, Andrew will soon be on the mend (vaccine reactions typically clear up in a few days).
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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