Find comprehensive information on Tdap vaccine administration, including CPT codes for Tdap, ICD-10-CM diagnosis codes for pertussis and tetanus, documentation requirements for Tdap immunization, Tdap vaccine billing guidelines, and proper medical coding for Tdap administration in healthcare settings. Learn about Tdap dosage, administration routes, and patient education resources for Tdap vaccination. This resource helps clinicians ensure accurate and compliant coding and documentation for Tdap vaccine administration.
Also known as
Encounter for immunization
Encounters for prophylactic vaccination and inoculation against infectious diseases.
Factors influencing health status
Contact with and suspected exposure to communicable diseases.
External causes of morbidity
May be used to explain how an injury or poisoning occurred.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is Tdap administration for routine prophylaxis?
Yes
Code Z23
No
Is it for wound management?
When to use each related code
| Description |
|---|
| Tdap administration |
| Td vaccine administration |
| Pertussis infection |
Coding error risk: Documentation lacks clarity on whether the Tdap was adult, adolescent/child, or unspecified formulation leading to incorrect code selection.
Coding/audit risk: Insufficient documentation of administered dosage can lead to claim rejections and compliance issues.
Coding error risk: Clinicians may document Td when Tdap was given, or vice versa, leading to incorrect coding and potential under or overpayment.
Tdap vaccination administered. Patient presented for routine immunization with Tdap vaccine. Personal and family history reviewed. Patient reported no contraindications to Tdap vaccination, including no history of anaphylaxis or severe reaction to previous tetanus, diphtheria, or pertussis containing vaccines. Patient denies current febrile illness. Informed consent obtained after discussing the risks and benefits of Tdap immunization, including local injection site reactions such as pain, redness, and swelling, as well as systemic reactions such as fever, headache, and fatigue. The adult formulation of Tdap vaccine was administered intramuscularly in the deltoid muscle of the left arm. Patient tolerated the procedure well. Post-vaccination care instructions provided, including monitoring for adverse reactions and guidance on managing local site reactions. Patient education regarding the importance of Tdap vaccination for preventing tetanus, diphtheria, and pertussis was reinforced. Documentation of vaccine manufacturer, lot number, and expiration date recorded in the patient's electronic health record. Scheduled follow-up as indicated for subsequent vaccinations per recommended guidelines.