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2025 ICD-10-CM code T78.2

Anaphylactic shock, unspecified; this code is used when the cause of the anaphylactic shock is unknown.

Use this code only when a more specific anaphylaxis code from T78.0-T78.1 is not applicable.Always refer to the latest version of the ICD-10-CM coding guidelines for complete instructions.

Modifiers may apply depending on the context of the encounter and the services provided.Consult the appropriate modifier guidelines.

Medical necessity is established by the presence of signs and symptoms consistent with anaphylactic shock requiring immediate medical intervention.Documentation must support the severity of the reaction and the need for treatment in an emergency setting. If testing is done and fails to identify a cause, this must be well documented.

The clinical responsibility involves diagnosing the anaphylactic shock, stabilizing the patient’s condition, and determining the cause of the reaction if possible. This includes administering appropriate treatment (e.g., epinephrine), monitoring vital signs, and managing respiratory support.

IMPORTANT:Consider more specific codes from T78.0-T78.1 (anaphylactic shock due to specified causes) if the cause is known.If a foreign body is involved, code Z18.- should be added.

In simple words: This code describes a severe allergic reaction called anaphylactic shock when doctors don't know what caused it.It's a serious condition that needs immediate medical attention because it can affect breathing and blood circulation.

This ICD-10-CM code, T78.2, classifies anaphylactic shock without specifying the cause.Anaphylactic shock is a severe, life-threatening allergic reaction that can lead to circulatory collapse and respiratory distress.This code is applied when a more specific cause of anaphylaxis (e.g., a particular food allergen, medication, or insect sting) cannot be identified or determined.It is crucial to note that this is a nonspecific code and should only be used when a more precise code is unavailable.Additional codes may be needed to specify the cause if known (Chapter 20, External causes of morbidity) and any retained foreign body (Z18.-).

Example 1: A patient presents to the emergency room with symptoms of anaphylaxis (hypotension, urticaria, angioedema, and respiratory distress), but the cause of the reaction remains unknown after a thorough history and physical examination., A patient experiences a sudden onset of severe allergic reaction while at home, with no clear trigger identifiable. EMS administers epinephrine en route to the hospital where the diagnosis of anaphylactic shock is made, yet the triggering allergen cannot be determined., A patient in the ICU develops a life-threatening allergic reaction with symptoms consistent with anaphylactic shock. Though extensive testing is conducted, the origin of the hypersensitivity reaction remains elusive.

Detailed documentation should include the patient's presenting symptoms, vital signs, physical examination findings, treatment administered (including epinephrine dose and response), and any investigations performed to identify the potential allergen or cause of the anaphylactic shock.The documentation should justify the use of code T78.2 when a specific cause cannot be identified.

** This code should be used cautiously, prioritizing more specific codes whenever possible.Accurate documentation is crucial to justify the use of this non-specific code.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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