2025 ICD-10-CM code T78.2XXA
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Other and unspecified effects of external causes (T66-T78) Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Anaphylactic shock, unspecified, initial encounter.
Medical necessity for the diagnosis and treatment of anaphylactic shock is established by the presence of life-threatening symptoms such as hypotension, airway compromise, and circulatory collapse requiring emergency intervention.Proper documentation of the severity of the reaction and the immediate need for medical attention is crucial to supporting medical necessity.
The clinical responsibility for this code would involve the immediate stabilization and treatment of the patient's anaphylactic shock. This includes administering epinephrine, managing airway patency, supporting respiration and circulation, and monitoring vital signs.Further investigation to identify the triggering allergen is also a key component of clinical responsibility.
- Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injury, poisoning and certain other consequences of external causes (T07-T88)
In simple words: This code is for a serious allergic reaction called anaphylactic shock when the doctor doesn't know what caused it. It's a sudden, dangerous reaction that makes it hard to breathe and can cause a person's blood pressure to drop dramatically. The doctor will likely try to find out what triggered the reaction later.
This code classifies anaphylactic shock as the initial encounter, where the specific cause is unknown. Anaphylactic shock is a severe, life-threatening allergic reaction involving the entire body. It's characterized by a sudden drop in blood pressure, rapid pulse, difficulty breathing, hives, and swelling.The unspecified nature highlights the absence of a definitively identified allergen or trigger at the time of the initial encounter.Further investigation might be needed to pinpoint the cause.
Example 1: A patient presents to the emergency department with sudden onset of shortness of breath, hypotension, and urticaria after eating an unknown food.T78.2XXA is used to describe the anaphylactic shock initially. Subsequent investigation might lead to a more specific code once the allergen is identified., A patient receiving an intravenous medication experiences a rapid drop in blood pressure, swelling of the throat, and wheezing. T78.2XXA is assigned to document the initial diagnosis, with potential for later refinement depending on allergy testing results., A patient develops symptoms consistent with anaphylaxis (hypotension, tachycardia, angioedema) after an insect sting of uncertain species. T78.2XXA is used pending identification of the insect and assessment of the allergy.
Detailed documentation should include the patient's presentation, vital signs, description of symptoms, any medications administered (especially epinephrine), and the results of any allergy testing performed to determine the cause of the anaphylactic shock. This should also include the time course of the reaction.Include any history of allergies.
** This code is for the initial encounter only.If subsequent visits are needed, a different seventh character should be utilized (D, I, or S).
- Payment Status: Active
- Specialties:Allergy and Immunology, Emergency Medicine
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital