Cracking the Code

Allergic Reaction to COVID-19 Vaccine

There has been confusion across the board when it comes to correctly coding COVID-19. A lot of medical coders are not sure which diagnoses to assign nor how to appropriately assign them. When a provider documents that a patient has an allergic reaction to COVID-19 vaccine, it is NOT appropriate to assign a diagnosis from subcategory T80.62XA-, other serum reaction due to vaccination, initial encounter because the current approved COVID-19 vaccines in the United States are not serum based. For these encounters, it is appropriate to assign T78.49XA, other allergy, initial encounter as the primary diagnosis followed by any signs, symptoms, or definitive conditions as secondary diagnoses. Please keep in mind that COVID-19 guidance is fluid, so it may change in the future. However, this is proper protocol for now.

Q: A patient presents to the ED with complaints of chest tightness after receiving their first shot of the COVID-19 vaccine. The provider diagnoses the patient with allergic reaction to COVID-19 vaccine and discharges the patient home.
A: T78.49XA, other allergy, initial encounter; R07.89, other chest pain
Reference: AHA Coding Clinic First Quarter 2021, page 42: Allergic reaction to COVID-19 vaccine
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