Immunization Coding for Obstetrician-Gynecologists

Introduction

Immunizations are recommended as part of comprehensive care for women. Under the Patient Protection and Affordable Care Act (ACA), vaccines recommended by the Advisory Committee on Immunization Practices are required to be provided with no cost sharing (ie, no co-pay) for children, adolescents, and adults. Check the list of vaccines covered for more information about the ACA.

Below are some of the most common ICD-10 diagnosis and CPT/HCPCS codes related to immunizations. These lists are not all inclusive. Additional characters may be required for appropriate code selection. For assistance with proper code selection/use, you may refer to the most recent official copies of each of the following: ICD-10-CM book, ACOG’s OB/GYN Coding Manual, American Medical Association Current Procedural Terminology Professional Book and Health Care Common Procedure Coding System books. Proper coding may require analysis of statutes, regulations or carrier policies and, as a result, the proper code result may vary from one payer to another.

This resource will cover the following:

Reimbursement for Vaccinations
Coding for Vaccinations
- ICD-10-CM Diagnosis Codes for Vaccination Services
- Current Procedural Terminology and Medicare Coding for Vaccinations
Coding Resources

Reimbursement for Vaccinations

Reimbursement for vaccinations will vary by payer. Please refer to your payer contract for details.

Medicare

Medicare Part B does not cover other immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition (eg, tetanus or exposure to rabies). The ICD-10-CM diagnosis code attached to the vaccine must define the disease or condition. Medicare Part B currently covers preventive vaccine costs for influenza; pneumococcal conjugate and pneumococcal polysaccharide; Hepatitis B; and COVID-19.

Medicare typically pays for only one influenza vaccination per year. If more than one vaccination is medically necessary (eg, multiple doses are required), then Medicare will pay for those additional vaccinations. If a patient receives the influenza vaccine and a pneumococcal pneumonia virus vaccine during the same visit, use diagnosis code Z23.

The pneumococcal vaccine is paid once per patient in most cases. However, Medicare will reimburse for revaccination if the patient is considered to be at the highest level of risk of a serious pneumococcal infection and for patients likely to have a rapid decrease in pneumococcal antibody levels. At least 5 years must have passed since the most recent dose of this vaccine.

Hepatitis B vaccinations are reimbursed only for Medicare beneficiaries considered to be at highest risk and those most likely to have rapid decreases in antibody levels. Medicare defines the highest-risk patients as those with functional or anatomic asplenia, human immunodeficiency virus (HIV) infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression.

The prescription drug plan, Medicare Part D covers other preventive vaccines. If a patient has Medicare Part D coverage, it is likely that they have preventive coverage for most vaccines.

Medicaid

Medicaid reimburses for routine immunizations for covered individuals younger than 21 years. For these individuals, there are two different programs that provide these services:

Patients aged 19–20 years receive routine immunizations as part of the Early and Periodic Screening, Diagnostic, and Treatment program. This public program for low-income and medically indigent individuals is administered on a state-by-state basis and should contact the state Medicaid program for more information.
Patients 18 years or younger receive vaccinations through the state’s Vaccines for Children (VFC) program described below.

Vaccines for Children Program

The Vaccines for Children (VFC) program provides free vaccines to doctors who serve eligible children. It is administered at the national level by the CDC through the National Immunization Program. The CDC contracts with vaccine manufacturers to buy vaccines at reduced rates. Eligible children are those who meet the following criteria:

Are eligible for Medicaid
Are 18 years or younger
Have no health insurance
Are Native American or Alaska Native
Have health insurance but no immunization coverage. In these cases, these children must go to a federally qualified health center or rural health clinic to receive their immunizations.

Vaccinations are provided for the following diseases:

Diphtheria
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Human papillomavirus
Influenza
Measles
Meningococcal disease
Mumps
Pertussis (whooping cough)
Pneumococcal disease
Polio
Rotavirus
Rubella
Tetanus
Varicella

For more information on VFC or how to become a VFC provider, visit CDC’s website.

Private/Commercial Plans

The Affordable Care Act mandates that most private insurance plans, including those in the marketplace, cover specific vaccines without cost to the patient when provided by an in-network provider, including those patients who have not met the annual deductible.

Vaccines typically covered without cost-sharing include:

Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Influenza
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Tetanus, Diphtheria, Pertussis
Varicella

Refer to the patient’s coverage for specific billing and coding instructions, including any limitations that may related to same-day billing of evaluation and management services.

Coding for Vaccinations

ICD-10-CM Diagnosis Codes for Vaccination Services

The diagnosis codes for an encounter for vaccinations are found in the Z code category (Factors Influencing Health Status and Contact With Health Services) of ICD-10-CM. If a patient is being seen for a specific disease or symptom, report the code for the disease or symptom as well as a code for the vaccination.

Diagnosis codes used for vaccinations are categorized as follows:

Individuals with potential health hazards related to communicable diseases, including patients who have been exposed to or had contact with someone with a communicable disease
Encounters for inoculations and vaccinations, including prophylactic administration of vaccines
Encounters during which a planned immunization was not carried out

Table 1. The diagnosis codes most likely to be reported when vaccinations are administered to individuals with potential health hazards related to communicable diseases are listed as follows (excludes: carrier of infectious disease [Z22.-*], diagnosed current infectious or parasitic disease [Z22], and personal history of infectious and parasitic diseases [Z86.1-*]):

Z Code	Description
Z20	Contact with and (suspected) exposure to communicable diseases
Z20.1	Tuberculosis
Z20.3	Rabies
Z20.4	Rubella
Z20.82	Contact with and (suspected) exposure to other viral communicable diseases
Z20.820	Varicella
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases
Z20.81-*	Contact with and (suspected) exposure to other bacterial communicable diseases
Z20.811	Meningococcus
Z20.9	Contact with and (suspected) exposure to unspecified communicable diseases
Z23	Encounter for immunization
Z51.89	Encounter for other specified aftercare
Z41.8	Encounter for other procedures for purposes other than remedying health state

Table 2. Immunization not carried out and underimmunization status:

Z Code	Description
Z28	Immunization not carried out and underimmunization status
Z28.0	Immunization not carried out because of contraindication
Z28.01	Immunization not carried out because of acute illness of patient
Z28.02	Immunization not carried out because of chronic illness or condition of patient
Z28.03	Immunization not carried out because of immunecompromised state of patient
Z28.04	Immunization not carried out because of patient allergy to vaccine or component
Z28.09	Immunization not carried out because of other contraindication
Z28.1	Immunization not carried out because of patient decision for reasons of belief or group pressure
Z28.20	Immunization not carried out because of patient decision for unspecified reason
Z28.21	Immunization not carried out because of patient refusal
Z28.29	Immunization not carried out because of patient decision for other reason
Z28.81	Immunization not carried out due to patient having had the disease
Z28.82	Immunization not carried out because of caregiver refusal (Excludes 1: Immunization not carried out because of caregiver refusal because of religious belief [Z28.1])
Z28.83	Immunization not carried out due to unavailability of vaccine
Z28.89	Immunization not carried out for other reason

Current Procedural Terminology and Medicare Coding for Vaccinations

Vaccination Procedures

A vaccination procedure has two components: 1) the administration of the vaccine and 2) the vaccine product (drug) itself. The administration may be performed by the obstetrician– gynecologist or other health care provider. When the vaccine drug and the administration are provided by the physician office, report a code for the vaccine and a code for administration of the vaccine.

Codes for Administration of the Vaccine

The administration codes specify the method and route of administration (see Table 3 for CPT codes). Medicare and CPT use the same set of codes to report administration of most vaccines.

Table 3. Current Procedural Terminology Codes for Vaccine Administration (Single or Combination Vaccine/Toxoid)

Code	Method	Route of Administration	Type of Service	Reporting Rules
90460	Any route	Percutaneous, intradermal, subcutaneous, or intramuscular	Primary	Report for each vaccine administered. Physician also provides counseling. Patient is 18 years or younger.
90461	Any route	Percutaneous, intradermal, subcutaneous, or intramuscular	Each additional	Report for each additional component in a vaccine in conjunction with 90460. Physician also provides counseling. Patient is 18 years or younger.
90471	Injection	Percutaneous, intradermal, subcutaneous, or intramuscular	Primary	Report only one primary vaccine administration per encounter.
+90472	Injection	Percutaneous, intradermal, subcutaneous, or intramuscular	Each additional	Report for secondary or subsequent vaccine administration. Report only with code 90460, 90471, or 90473.

Medicare requires special HCPCS codes for the administration of influenza, pneumococcal, or hepatitis B vaccines (see Table 4). Note that some commercial carriers also accept these HCPCS codes. A summary of these codes follows.

Table 4. Medicare’s Healthcare Common Procedure Coding System Codes for Vaccine Administration

Code	Vaccine	Specific Method	Type of Service
G0008	Influenza	Injection	Primary
G0009	Pneumococcal	Injection	Primary
G0010	Hepatitis B	Injection	Primary

There are no specific HCPCS codes for administration of other vaccines. In these cases, Medicare accepts the appropriate CPT code for the vaccine administration.

Codes for the Vaccine Drug Product

Current Procedural Terminology and Medicare use CPT codes 90476–90749 to report the vaccine drugs.

Table 4, Table 5, Table 6, and Table 7 summarize coding for vaccines and their administration under CPT and Medicare rules.

Immunization administration codes for patients younger than 18 include:

90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
+90461 Each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

The following are administration codes for ages 18 and older:

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
+90472 Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure.)
90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
+90474 Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure.)

Table 5. Vaccines Commonly Administered to Adolescents and Adults (Report an Administration Code and a Vaccine Code)*

Vaccine	Code for Vaccine Product	CPT Administration Code	Medicare Administration Code
Hepatitis A vaccine (HepA), adult dosage, for intramuscular use	90632	90471–90472	90471–90472
Hepatitis A vaccine (HepA), pediatric/adolescent dosage, -2 dose schedule, for intramuscular use	90633	90460–90472	90471–90472
Hepatitis A vaccine (HepA), pediatric/adolescent dosage, -3 dose schedule, for intramuscular use	90634	90460–90472	90471–90472
Hepatitis B vaccine (HepB), adolescent, 2dose schedule, for intramuscular use	90743	90460–90472	G0010
Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3dose schedule, for intramuscular use	90744	90460–90472	G0010
Hepatitis B vaccine (HepB), adult dosage, 3dose schedule, for intramuscular use	90746	90471–90472	G0010
Hepatitis B vaccine (HepB), adult dosage, 2dose schedule, for intramuscular use	90739	90471–90472	G0010
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3dose schedule, for intramuscular use	90740	90471–90472	G0010
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4dose schedule, for intramuscular use	90747	90471–90472	G0010
Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use	90636	90471–90472	90471–90472
Human papillomavirus vaccine types 6, 11, 16, 18 (quadrivalent); 3dose schedule, for intramuscular use	90649	90460–90472	90471–90472
Human papillomavirus vaccine types 16, 18 (bivalent); 3dose schedule, for intramuscular use	90650	90460–90472	90471–90472
Human papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2or 3dose schedule, for intramuscular use	90651	90460–90472	90471–90472
Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use	90733	90460–90472	90471–90472
Meningococcal conjugate vaccine, serogroups A, C, W, Y,, quadrivalent, diphtheria toxoid carrier (MenACWY-D) or CRM197 carrier (MenACWY-CRM), for intramuscular use	90734	90460–90472	90471–90472
Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use	90670	90460–90472	G0009
Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use	90732	90460–90472	90471-90472
Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use	90714	90460–90472	90471-90472
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use	90715	90460–90472	90471-90472
Varicella virus vaccine (VAR), live, for subcutaneous use	90716	90460–90472	90460–90472
Varicella-zoster immune globulin, human, for intramuscular use	90396	90460–90472	96372
Zoster (shingles) vaccine (HZV), live, for subcutaneous injection	90736	90471–90472	90471–90472
Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use	90750	90471–90472	90471–90472

*Note: Influenza codes are outlined in Table 6.
Abbreviation: CPT, Current Procedural Terminology.

Table 6. Coding for Influenza Vaccines

Vaccine (Description)	Code for Vaccine Product	Administration Code
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use	90630	90460–90472
Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use	90653	90460–90472
Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use	90654	90460–90472
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use	90655	90460–90472
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use	90656	90460–90472
Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use	90657	90460–90472
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use	90658	90460–90472
Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use	90661	90460–90472
Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use	90662	90460–90472
Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use	90673	90460–90472
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use	90674	90460–90472
Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use	90682	90460–90472
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL, for intramuscular use	90685	90460–90472
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use	90686	90460–90472
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use	90687	90460–90472
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use	90688	90460-90472
Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use	90689	90460–90472
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use	90756	90460–90472

Table 7. Medicare Coding for Influenza Vaccines

Vaccine	Code for Vaccine Product	Administration Code (CPT and Medicare)
Influenza virus vaccine, split virus, for intramuscular use (Agriflu)	Q2034	G0008
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)	Q2035	G0008
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)	Q2036	G0008
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)	Q2037	G0008
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)	Q2038	G0008
Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)	Q2039	G0008

Table 8. Vaccines Commonly Administered for Travel (Report an Administration Code and a Vaccine Code)

Vaccine	Code for Vaccine Product	Administration Code
Rabies vaccine, for intramuscular use	90675	90460–90472
Rabies vaccine, for intradermal use	90676	90460-90472
Typhoid vaccine, live, oral	90690	90460–90461
Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use	90691	90460–90472
Yellow fever vaccine, live, for subcutaneous use	90717	90460–90472

Coding Resources

Coding for COVID-19 Immunizations

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