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
- 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. |
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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