2025 ICD-10-CM code T88.1
Other complications following immunization, not elsewhere classified. This includes generalized vaccinia and rash following immunization.
Seventh character is required for this code to specify the encounter type:A - Initial encounterD - Subsequent encounterS - Sequela
Medical necessity for the use of this code is established by the presence of a complication following immunization that requires medical attention beyond the expected mild reactions.The documentation should support the diagnosis and the need for intervention.
The clinician is responsible for observing the patient for any adverse reactions following immunization and providing appropriate medical care if complications arise. This includes documenting the specific complication, the vaccine administered, and any treatment provided.
In simple words: This code represents other complications that can occur after receiving an immunization, which are not classified elsewhere. Examples include a generalized vaccinia infection or a rash.
Other complications following immunization, not elsewhere classified. Examples include: Generalized vaccinia and Rash following immunization.
Example 1: A patient develops a generalized vaccinia infection after receiving a smallpox vaccine., A patient experiences a severe rash after receiving the MMR vaccine., A patient develops localized swelling and redness at the injection site beyond the typical mild reaction, requiring medical intervention.
Documentation should include the type of immunization given, the date of administration, a detailed description of the complication, and any treatment provided. If a rash is present, its characteristics (e.g., location, appearance, duration) should be documented.It’s crucial to differentiate the adverse reaction from other potential diagnoses.
** For any retained foreign body related to the immunization, use an additional code from the Z18.- series.If the complication is an adverse effect of a drug, use an additional code from T36-T50 with a fifth or sixth character of 5.Also, code any specified condition resulting from the complication.
- Specialties:Allergy and Immunology, Pediatrics, Family Medicine, Internal Medicine, Infectious Disease
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital, Public Health Clinic