EDITORS NOTE: This article has been updated to include a code that should be used for an allergic reaction to vaccines.
Vaccination coding and billing questions answered.
COVID-19 vaccination is ramping up. We wrapped up Vaccination Nation month at the end of February. I have been fielding questions about COVID-19 vaccination coding and billing, so I thought I would share that with you today.
If you have taken the time, energy, and resources to set up a vaccinating process, you are entitled to receive appropriate compensation. I am not going to opine on whether the compensation is commensurate to the time, energy, and resources you are utilizing, however, you should get paid.
Vaccine is being federally purchased at this time, so there is no charge or reimbursement for the vaccine which is provided by the government. Medicare patients are not billed for any charges such as copayments, coinsurance, or deductibles. It is also stipulated that people without health insurance or whose insurance does not provide coverage for vaccination administration can get COVID-19 vaccine at no cost. Reimbursement can be requested through the Provider Relief Fund.
The Medicare payment rates for COVID-19 vaccine administration is $28.39 for single-dose vaccines (there are no single-dose vaccines under EUA or federally approved at this time); and $16.94 for the first shot and $28.39 for the second or final dose for multiple-dose regimens. The link for the current codes and allowances is here. Other insurers are either reimbursing at contracted or Medicare rates.
There is only one ICD-10-CM code which is utilized: Z23, Encounter for immunization. This is a generic immunization code; there is no specific COVID-19 counterpart. The ICD-10-CM code indicates that a vaccination was given; the CPT code/s indicate which vaccine it was.
The two-dose COVID-19 vaccines that we currently have available to use under EUA are Pfizer and Moderna. Billing for vaccine administration requires two CPT codes – one to identify the manufacturer and one to signify which dose it was.
- Pfizer: 91300. First dose: 0001A, second dose: 0002A.
- Moderna: 91301. First dose, add: 0011A, second dose: 0012A.
There are codes queued up for AstaZeneca and Janssen/Johnson & Johnson vaccines as well ( See: List of COVID-19 vaccines and monoclonal antibody codes and payment allowances).
Someone posed a scenario where the provider diagnosed, “post vaccination weakness and mental status changes,” for a patient who became lethargic and confused after their second COVID-19 vaccination shot. There was some discussion in her facility as to how to best capture this.
The central issue of this question is what constitutes an adverse effect. Many medications have side effects. Some are expected, and if they don’t require any resources or treatment, they wouldn’t be considered “adverse effects.” Sleepiness from diphenhydramine is not an adverse effect if you are using it for bedtime sedation. Side effects can be desirable, like increased appetite from steroids in a patient who is malnourished. Again, this would not be considered an “adverse effect.”
If a side effect is detrimental and pronounced, requiring medical attention, work-up, or treatment, then it is an adverse effect. Medication X is known to cause nausea…not an adverse effect if mild nausea occurs. If a patient taking Medication X presents to the emergency department with intractable vomiting and requires antiemetics, intravenous hydration, and a 24-hour observation stay à adverse effect.
Adverse effects can also be “adverse events.” Serious adverse events result from medications or medical products with outcomes such as death, life-threatening reactions, hospitalization, disability, congenital anomalies, necessity for intervention to prevent permanent impairment or damage, or other serious outcomes. Adverse events are reported to the U.S. Food and Drug Administration (FDA).
There is a national website where adverse events following vaccines are reported, but there is a disclaimer that causation cannot be assumed (Vaccine Adverse Event Reporting System (VAERS)). Providers or patients can submit reports. Examples of reactions which are considered reportable are anaphylaxis, shoulder injury related to vaccine administration, and vasovagal syncope within 7 days of receiving vaccination. The instructions are to report “any clinically important medical event or health problem that occurs after vaccination” “even if you are not sure if it was a result of vaccination.” There is also an app being touted to monitor side effects, v-safe (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe.html). I have been recommending my vaccinees download and use it.
Anaphylaxis to COVID-19 vaccine is the only absolute contraindication for vaccination against COVID-19, and it is easy to code: T80.52XA, Anaphylactic reaction due to vaccination, initial encounter. An allergic reaction short of anaphylaxis would be coded with T50.B95A, for Adverse effect of other viral vaccines, initial encounter, and the manifestation, such as L50.0, Allergic urticaria (indexed “urticaria due to drugs”). [Article revision 3/10/21: AHA/AHIMA FAQs rev. 3/1/21 recommends the manifestation of an allergic reaction to COVID-19 be coded with T78.49XA, Other allergy initial encounter]
It won’t surprise me if they make a dedicated COVID-19 vaccine code, but for now, the only viral vaccine that has its own code set is smallpox. If a patient were to seek medical attention for severe (even if expected) symptoms, like myalgias, headache, chills, or nausea, T50.B95A would be appropriate. Postvaccination fever is R50.83, and I would use it as a manifestation with T50.B95A. I believe adverse effects are a result of the medication (vaccine) properly administered but resulting in undesirable symptoms requiring action. Most of these side effects occur within 1-2 days of the injection.
The other code considered by the questioner’s team was T88.1XXA, Other complications following immunization, not elsewhere classified, initial encounter. In my opinion, there are several situations which warrant this code. Complications directly related to the procedure of immunization, but not related or due to the medication per se, might fit into this code. If a patient sought treatment because the injection was erroneously placed into their deltoid tendon or their shoulder joint, that would be T88.1XXA. A large hematoma or a firm lump from a resolving hematoma…T88.1XX- (7th character of “S” if it were a sequela). They are finding that patients develop localized rashes over the injection site, known as “COVID Arm,” or generalized rashes. These index to T88.1XX-.
They have changed mammogram guidelines due to the occurrence of ipsilateral axillary lymphadenopathy after COVID-19 vaccination. I believe that the correct coding for that would be R59.0, Localized enlarged lymph nodes plus T88.1XXA. Finally, T88.1XXA might also be appropriate if it isn’t incontrovertible that the vaccine directly was causing the abnormal reaction or complication, like the example above of the reportable complication of vasovagal syncope within a week of being vaccinated. If a patient were to develop an abscess in the injection site, T88.0XXA, Infection following immunization, initial encounter, is the ICD-10-CM code.
If a patient presents with a known significant allergy to COVID-19 vaccine, they would have pre-existing Z88.7, Allergy status to serum and vaccine. This might lead to Z28.04, Immunization not carried out because of patient allergy to vaccine or component.
Let’s circle back to the original question, “post vaccination weakness and mental status changes.” The codes I would select for the documentation of this case would be: R53.1, Weakness, R41.82, Altered mental status, unspecified, and T50.B95A, Adverse effect of other viral vaccines, initial encounter.
If you have submitted questions to AHA Coding Clinic and have gotten different advice, please let me know. I am not a coder; I just play one on the computer.
Remember, side effects are relatively common with COVID-19 vaccinations. Adverse effects, complications, and anaphylaxis, however, are uncommon.
Programming Note: Listen to Dr. Erica Remer on Talk Ten Tuesdays every Tuesday at 10 a.m. Eastern.