ICD-10 Coding for Underimmunization Status(Z28.310, Z28.311, Z28.39)
Complete ICD-10-CM coding and documentation guide for Underimmunization Status. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Underimmunization Status
Z28.3Primary Range
Underimmunization status
This range includes codes for patients who are unvaccinated or partially vaccinated, impacting clinical care and public health.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z28.310 | Unvaccinated for COVID-19 | Use when a patient is completely unvaccinated for COVID-19 and this status impacts clinical care. |
|
| Z28.311 | Partially vaccinated for COVID-19 | Use when a patient has received some COVID-19 vaccines but is not up to date. |
|
| Z28.39 | Other underimmunization status | Use when underimmunization for non-COVID vaccines impacts clinical care. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for non-immune status
Essential facts and insights about Underimmunization Status
Primary ICD-10-CM Codes for non immune
Decision Criteria
clinical Criteria
- Patient has not received any COVID-19 vaccines.
documentation Criteria
- Documented refusal or absence of vaccination records.
Applicable To
- Patients who have not received any COVID-19 vaccines
Excludes
- Patients with medical contraindications to COVID-19 vaccines
Clinical Validation Requirements
- Documented refusal of all COVID-19 vaccines
- Patient history indicating no COVID-19 vaccination
Code-Specific Risks
- Incorrectly coding patients with contraindications as unvaccinated
Coding Notes
- Ensure documentation clearly states the patient's vaccination status and any counseling provided.
Z28.311 - Partially vaccinated for COVID-19
Use when a patient has received some COVID-19 vaccines but is not up to date.
Applicable To
- Patients who have received some but not all COVID-19 vaccines
Excludes
- Fully vaccinated patients
Clinical Validation Requirements
- Patient records showing partial COVID-19 vaccination
- Documentation of missed doses
Coding Notes
Ensure documentation specifies which vaccines have been received and which are missing.
Z28.39 - Other underimmunization status
Use when underimmunization for non-COVID vaccines impacts clinical care.
Applicable To
- Underimmunization for vaccines other than COVID-19
Excludes
- Fully vaccinated patients for all recommended vaccines
Clinical Validation Requirements
- Patient history showing missed routine vaccinations
- Documentation of specific vaccines not administered
Coding Notes
Document specific vaccines missed and any clinical impact.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Underimmunization Status to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z28.310.
Impact
Clinical: May lead to inappropriate clinical decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Use specific language regarding vaccine status, Document counseling sessions
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and public health data.
Mitigation Strategy
Use appropriate contraindication codes instead of Z28.310.
Impact
Using underimmunization codes without proper documentation.
Mitigation Strategy
Ensure all vaccine refusals and counseling are documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Underimmunization Status, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Underimmunization Status
Use these documentation templates to ensure complete and accurate documentation for Underimmunization Status. These templates include all required elements for proper coding and billing.
Patient unvaccinated for COVID-19
Specialty: Primary CareRequired Elements
- Vaccination status
- Reason for non-vaccination
- Clinical impact
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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