I’m “Underimmunized” and Proud of It!
There has been a fair amount of attention to recently created International Classification of Disease (ICD) diagnosis codes for various states of Covid-19 vaccination status in a person. The tenth version of ICD (heretofore referred to as ICD-10) comprises a set of diagnosis codes for every imaginable medical condition, as well as risk factors for conditions that haven’t manifest yet, such as “Family History of Diabetes Mellitus” (Z83.3). Diagnosis codes can significantly affect reimbursement for healthcare services (but don’t think codes are chosen without documentation of the diagnosis, its status, severity, etc—deliberate misuse of ICD-10 codes would be fraud and can and does result in significant penalties to healthcare providers and/or organizations).
In 2022 the Center for Disease Control (CDC) created ICD-10 codes for a person’s specific vaccination status –as in, unvaccinated (Z28.310) for Covid-19 or partially vaccinated (Z28.311)for Covid-19 (ICD-10-CM (cdc.gov)) . As best I can tell, there has been a code for “underimmunization”—Z28—for at least several years. You can deduce this by looking at the revisions at the CDC site by fiscal year. This general underimmunization code has been present since at least 2019, but there is no specific vaccination implicated with it. However, for FY 2023 this code is expanded and there are values that apply specifically to Covid-19 vaccination. I do not see similar codes for any other vaccine.
Jessica Rose explored this action in detail in a series of Substack posts,
and
Robert Malone has also weighed in on the subject New diagnosis codes for COVID-19 immunization status (substack.com). Finally, there is a thoughtful essay at the Brownstone Institute penned by Dr. Harvey Risch considering the ramifications The Impending US ICD Vaccine Passport and Its Unconstitutionality ⋆ Brownstone Institute . Essentially, one can conclude the government is intending to track Covid-19 vaccination status in a way that has never been done before, as far as I know, as a general internist and primary care provider of some 30 years.
From a practical standpoint, these codes would need to be added to a medical record of a patient. They could be added to the Problem List—the list of a patient’s active problem and those that are a matter of historical interest from a clinical standpoint. For example, when a patient successfully achieves a cure of her breast cancer, I enter the code for “Personal History of Breast Cancer” (Z85.3) in the problem list, and “resolve” the active diagnosis of breast cancer as the patient is no longer on treatment for it. In my healthcare system only providers (doctors, nurse practitioners, physician assistants and nurses) can add, revise or delete a diagnosis to or from a Problem List.
Another place for the codes to be entered in the medical record would be at the time of an encounter at a healthcare facility or office—this could be an office visit or a hospitalization. If it is at the time of a hospitalization it could then be found in a database of hospitalizations, which many states maintain. These data sets are typically available for a nominal fee to individuals who want to analyze them, but they usually don’t have unique identifiers, so you can’t link episodes to create a longitudinal file on an individual, and certainly there is no information that would make it possible to identify the individuals specifically (SSNs, medical record numbers, etc).
The electronic health records (EHRs) that are currently in widespread use, essentially mandated by law, have very detailed information on patients. In addition, they often link to outside information, and can make this available to providers. For example, I can see the records of encounters my patients have at multiple health systems and offices other than mine, which you can imagine is excellent for continuity of patient care. The EHR I use is Epic™, which is in common use in the US; it has a two-way connection to the WA State Immunization Registry, for example. Despite this two-way connection I have frequently found that my patients’ charts in the EHR do not have all of their Covid boosters, or even sometimes their Covid primary immunization. Thus I routinely access the WA State Registry and typically find 1 or more shots that were not in the EHR, in 25-50% of my patients scheduled on a given day. I enter this information in their charts—I want to be sure I know how many shots they have had, which vaccine, and when. My impression is that the Registry is highly accurate although not 100%, but generally very very good—they have lot #s for most vaccine entries, for example. The EHR gets information from the WA State Registry, it is present in the patient’s record but doesn’t become a part of it until I click a button to add it into the patient’s Immunization tab.
I recently cared for one patient who had on his Problem List a code for Covid-19 vaccine refusal. These codes have been available for use since 4/1/2022 (ICD-10 Code for Partially vaccinated for COVID-19- Z28.311- Codify by AAPC). I have a primary care internal medicine panel of about 500 adults, thus all have been eligible for multiple covid-19 injections; I estimate about 15-20% are not vaccinated at all for Covid-19. I would guess about half of the vaccinated patients have received 4 or 5 Covid shots. Thus by my estimation, a majority of my patient panel is underimmunized. However I feel no need to use the Z codes for underimmunization. I have a substantial number of patients who also do not get flu shots—I have never seen a code for underimmunization or refusal used for them—and this is not something I would typically code for in an office visit.
I am embarrassed to say I recently discovered that I entered a dx code for Covid vaccination refusal on another patient I saw—in May 2021. This reminds me I was still in thrall to the Covid Narrative at that time. I talked to my patients about Covid vaccination as the vaccines rolled out, in early 2021; in fact, I know I told some of them that we were part of a giant experiment—those of us that were vaccinated were the experimental group, those not vaccinated comprise the comparison group. Clearly I said this without really having thought it through completely.
I would like to suggest that this development of diagnosis codes to identify lack of Covid vaccination to me really emphasizes the need for patients to be pro-active in their healthcare, and most specifically pay close attention to their records. Most healthcare systems and practices these days offer a "patient portal"--a connection for the patient to their chart in the EHR—typically via email and also an application – ours is called “MyChart”. While thinking on this topic I decided to tour my electronic medical record in Epic, via MyChart. It is not complete, but it has what is called my “health issues”, which I believe is my Problem List; it has visit notes with my primary care provider (PCP) going back a few years (these were mandated by law to be available to patients unless there is a “compelling reason” for the notes not to be shared); it has medications, lab results, allergies and an incomplete immunization record. For one thing, I have had multiple immunizations in the past, as a healthcare employee thru our Employee Health office, and these are not in my medical record. It only had one of my two Moderna shots in the primary series—when I saw that I asked my PCP’s team to enter the second one and this was done. I decided to formally request a copy of my record, so I completed a release of information, and look forward to seeing what I get! I may have to pay a charge for it, which is fine; I expect I may get it on disc.
I would like to close with a couple of additional thoughts. First of all, by my assessment a majority of the US population is underimmunized for Covid-19—which I define as not having received all doses of Covid-19 vaccination recommended for their age and type of shot received. I have seen no mandate anywhere to use these underimmunization codes, and also am not aware of any financial incentive for healthcare entities to code for them. Given the pressure and frantic pace of current healthcare, I wouldn’t expect these codes to be used without some incentive to the healthcare facilities (which, as we saw with Remdesivir use and Covid hospitalizations, could be put in place). Still, most insurance plans, including the governmental ones (Medicaid, Medicare and other governmental programs) are tying reimbursement for care to quality measures such as cancer screenings and diabetes control. These data are thus collected in reports and it would be pretty simple to add a vaccine measure to that. Some payers already compensate for childhood immunization rates. This means that providers and healthcare organizations have consistent and regular pressure to meet these metrics, to fully earn payment for the care they provide to patients.
I believe that the government can already know each citizen’s immunization status, as most states if not all have an Immunization Registry that is quite detailed. In these registries the providers of immunizations report those injections to the state, and this happens quite extensively outside of hospitals and doctor’s offices, except for childhood immunizations. I presume that it is the state registry information that is used in states’ analyses of their residents’ outcomes by immunization and Covid-19 infection status. Based on my experience, medical record information on immunization is NOT complete and I would not trust any studies using just medical record information for that.
As noted by Jessica Rose and other commentators, immunization status is personal information, and should be nobody’s business. We must be vigilant to see whether these ICD-10 codes are used. I would like to stress that, from a clinical standpoint, they are of no value to me as a practitioner. If something happens and their use is mandated, I would consider this addition to my problem list:
Z28.81 Immunization not carried out due to patient having had the disease
And, I would add that to any patient’s record with their permission, if they have had Covid-19 and are underimmunized. As it happens, I document each patient’s Covid infection as
Z86.16 Personal history of COVID-19
on their Problem List. I am interested in when they had it, what their treatment was, and their symptoms and I put some notes about this in the record. This is especially important to me as I consider prior Covid infection to be a very strong reason to not get a Covid vaccination or booster.
In conclusion, it would be fairly simple for the government to institute an incentive to health care systems that causes them to make a priority of recording Covid-19 vaccine status, if that is desired. To date I have not seen any activity indicating this has happened. I personally think the government could determine everyone’s vaccinated status by accessing state immunization records. I have also wondered lately about the frequent practice of schools requiring that students have immunization records on file. Perhaps this is something that should be reconsidered? What is the schools’ compelling interest in having these records? I would never have asked this question were it not for the Covid Plandemonium (see The Plandemonium - Campfire Wiki).
Is there a code for being injured by the toxxine specifically?