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.
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This resource will cover the following:
- Reimbursement for Vaccinations
- Medicare
- Medicaid
- Vaccines for Children Program
- Private/Commercial Plans
- 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
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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. Coding for RSV Vaccines Administration
Vaccine (Description)
Code for Vaccine Product
Administration Code
Administration
Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified healthcare professional.
90380 – 90381
96380
*Infants < 8 months (during 1st RSV season) *8 months – 19 months (Children with increased risk of severe RSV disease during 2nd RSV season)
Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection.
90380 – 90381
96381
*Infants < 8 months (during 1st RSV season) *8 months – 19 months (Children with increased risk of severe RSV disease during 2nd RSV season)
Vaccine Codes for Adult Population Use
Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use
90678
90460 – 90480
*Adults 60 years and older *Pregnant patient at 32-36 weeks gestation (2nd/3rd trimester of pregnancy)
Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use
90679
90460 – 90480
*Adults 60 years and older
Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use
90683
90460 – 90480
*Adults 60 years and older
Table 9. 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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