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Coding for Vaccine Services

Understanding Types Of Medical Coding

When filing a claim, it is important to report the vaccine product code and administration code for each respective vaccine provided, in addition to the office visit and any other related services/procedures performed on the same date of service.1,2 You will find specific codes for certain GSK pediatric, adolescent, and adult vaccines in the Codes for GSK Vaccines section of this website.

In coding for vaccine services, it is also important to consider the use of Current Procedural Terminology (CPT) codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, and National Drug Codes (NDCs).

CPT Codes

CPT codes are part of a coding system published and maintained by the American Medical Association, and they generally consist of 5-digit numeric codes that identify medical services and procedures.3

There are two types of CPT codes related to vaccines: Product Codes and Administration Codes.

Product Codes

90476 – 90759

This range of codes is used to identify individual vaccine products, and they are reported in addition to the vaccine administration codes.4

Administration Codes

90460

This code is applicable or may be used when the physician or other qualified healthcare professional provides counseling during immunization of a patient through 18 years of age. When appropriate, the add-on code 90461 is included for each additional antigen contained per vaccine.4

90471 – 90474

Codes in this range correspond to4:

  • Administration of any vaccine that is not accompanied by physician or other qualified healthcare professional counseling (patients under the age of 18)
  • Administration of any vaccine to patients 18 years of age or older

"G" Codes

For Medicare Part B billing, influenza and hepatitis B vaccine administration use another type of Healthcare Common Procedure Coding System (HCPCS) codes, known as “G codes”5:

G Codes

G0008

Used for the administration of influenza virus vaccine

G0010

Used for the administration of hepatitis B vaccine

TIP: It is important to code vaccine-related administrative services accurately for the purposes of maintaining consistent and complete documentation in the medical records. Such documentation may also be used to support billing claims.3

Evaluation & Management Codes

Evaluation and management (E/M) codes are another type of CPT code that indicate the medical reason for the visit and the type and level of service and/or care provided. The E/M code may also identify the health status of the patient and whether the patient is new or established. If the visit is for an immunization only, an E/M code is not required.6

Using CPT modifiers

  • With E/M codes: Modifier 25 may be added to these additional codes to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day.7 An E/M service may not be reimbursed with the product and administration services if a Modifier 25 is not utilized with the E/M service code.7
  • With vaccine CPT codes: Some state Medicaid/Managed Medicaid plans may also require “SL” (state-supplied vaccine) or “SK” (administration of a vaccine for a high-risk patient) modifiers.8,9

These are only a few of the modifiers that may be used with vaccines. It is important to verify requirements with your individual payers.

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Tip

Some insurers may have different rules around claim submission for separate services provided at the same visit, so be sure to check third-party coverage policies to see what is required.7 

ICD-10-CM Codes

The ICD-10-CM is a system used to classify and code all diagnoses; identifying why a patient needs treatment by documenting the medical necessity.10

Z23 is the ICD-10 code that identifies an encounter for immunization(s).

If a vaccine is given within the same visit as other services, eg, preventive healthcare, the ICD-10 code for that service would be primary, and Z23 would be a secondary ICD-10 code.6

ICD-10 code Z23 is reported for vaccine-related encounters for all vaccines given within the encounter.10

Z23 is the ICD-10 code that identifies an encounter for immunization(s).

If a vaccine is given within the same visit as other services, eg, preventive healthcare, the ICD-10 code for that service would be primary, and Z23 would be a secondary ICD-10 code.6

In some situations, additional ICD-10 codes should also be included: 

  • If a patient is being seen for a specific disease or symptom, the ICD-10 code(s) for that disease or symptom would be reported, as well as the Z23 ICD-10 if an immunization was given.
  • If the immunization is related to exposure (eg, the administration of a Tdap vaccine as a part of wound care), the ICD-10 code describing the exposure should be used as the primary diagnosis code for the vaccine, and Z23 should be used as the secondary code.11

There may be additional diagnosis codes indicating high-risk or exposure to communicable diseases. This is not a complete list of diagnosis codes. Please refer to the 2020 ICD-10-CM coding manual for specific guidance.

Doctor with patient photo

There may be additional diagnosis codes indicating high-risk or exposure to communicable diseases. This is not a complete list of diagnosis codes. Please refer to the 2020 ICD-10-CM coding manual for specific guidance.

Questions?

Find answers to frequently asked questions, along with additional resources, to guide you to the information you need.

Get help

GSK Codes Summary Sheet

Get a PDF of the most current CPT, CVX, MVX, and NDC codes for GSK vaccines.

Download

References:

  1. Bright futures coding for pediatric preventive care 2022. American Academy of Pediatrics. Accessed September 1, 2023. https://downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf
  2. 1500 health insurance claim form reference instruction manual for form version 02/12. July 2019. National Uniform Claim Committee. Accessed September 1, 2023. https://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2019_07-v7.pdf
  3. CPT® overview and code approval. American Medical Association. Accessed September 1, 2023. https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval
  4. CPT category I new vaccine codes (including incorporation of ACIP abbreviations listing) long descriptors. American Medical Association. Updated August 14, 2023. Accessed September 1, 2023. https://www.ama-assn.org/system/files/vaccine-long-descriptors.pdf
  5. HCPCS quarterly update. HCPCS October 2023 index. Centers for Medicare and Medicaid Services. Accessed September 1, 2023. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update
  6. When is it appropriate to report an evaluation & management service during immunization administration? American Academy of Pediatrics. Accessed September 1, 2023. https://downloads.aap.org/AAP/PDF/AAP%20Position%20Paper%20EM%20IA.pdf
  7. Understanding when to use modifier-25. American Academy of Family Physicians. Accessed September 1, 2023. https://www.aafp.org/pubs/fpm/issues/2004/1000/p21.html
  8. Vaccine and immunization. Harvard Pilgrim Health Care. November 2022. Accessed September 1, 2023. https://www.harvardpilgrim.org/provider/wp-content/uploads/sites/7/2020/07/H-6-VACCINE-PM.pdf
  9. Provider manual. California Health and Wellness. Revised October 2018. Accessed September 1, 2023. https://www.cahealthwellness.com/content/dam/centene/cahealthwellness/pdfs/CHW_Provider_Manual_10-09-2018.pdf
  10. 2021 ICD-10-CM official guidelines for coding and reporting. Centers for Medicare and Medicaid Services. Updated January 1, 2021. Accessed September 1, 2023. https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf
  11. Top questions on coding and billing for vaccines: avoiding common errors. National Adult and Influenza Immunization Summit. Accessed September 1, 2023. https://www.izsummitpartners.org/naiis-workgroups/access-provider-workgroup/coding-and-billing/top-questions/

 

Completing the CMS-1500 Claim Form

The CMS-1500 form is a paper version health insurance claim form for non-institutional providers.1 The electronic version is called an 837 file.1 It is used to report and bill medical claims prepared and submitted by most physicians and suppliers for a physician's professional services.1

Box 21 – Diagnosis1

Image of CMS-1500 Claim Form, Box 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Image of CMS-1500 Claim Form, Box 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Report the diagnosis codes (ICD-10) along with any other diagnoses relevant to the patient’s episode of care on this date of service.

Box 24 Shaded Area – NDC1

Image of CMS-1500 Claim Form, Box 24, Shaded Area
Image of CMS-1500 Claim Form, Box 24, Shaded Area

When submitting to payers who require a product NDC in addition to a CPT code, the NDC must be formatted correctly to avoid a claim denial. First, confirm which NDC the payer requires—the product carton, unit-of-use (vial or syringe)—or if either are acceptable.

Then, enter the NDC in line 24A of the claim form:

  • Start with qualifier “N4” followed immediately (with no space) by the 11-digit NDC number with no hyphens.
  • GSK vaccines typically have 10-digit NDCs, so a “0” must be added immediately after the first hyphen in each NDC.

Next, add 1 space after the NDC to record Unit of Measure & Quantity.

Finally, add the Unit of Measure and Units Dispensed:

  • For reconstituted products, use Unit of Measure “UN” followed by the number of units administered (eg, UN1).
  • For liquid products, use Unit of Measure “ML” followed by the decimal quantity administered (eg, ML.5).

Box 24D – CPT/HCPCS1,2

Image of CMS-1500 Claim Form, Box 24D, CPT/HCPCS
Image of CMS-1500 Claim Form, Box 24D, CPT/HCPCS

Report the CPT codes for the vaccines administered. List E/M services first. Then list CPT codes for vaccines, vaccine administration, and ancillary services, considering age, counseling, and route of administration.

Box 24D – Modifier1

Image of CMS-1500 Claim Form, Box 24D, Modifier
Image of CMS-1500 Claim Form, Box 24D, Modifier

Append any necessary modifiers for proper claim processing.

Box 24E – Diagnosis Pointer1

Image of CMS-1500 Claim Form, Box 24E, Diagnosis Pointer
Image of CMS-1500 Claim Form, Box 24E, Diagnosis Pointer

Link the CPT codes to the ICD-10 code(s) in box 21 to support medical necessity.

Box 24G – Days or Units1

Image of CMS-1500 Claim Form, Box 24G, Days or Units
Image of CMS-1500 Claim Form, Box 24G, Days or Units

Units reported should be a whole number and correspond with the CPT code listed.  

Important Notes About NDCs

Some payers may require reporting of NDCs for vaccine products.1 When using GSK vaccines, it is important to check with your payers to understand which NDC should be used when completing a claim form and how to format based on payer requirements.

NDCs for GSK vaccines correlate to the various product presentations or component (eg, vial, syringe, product carton, etc.), which means a single product may have several NDCs3:

  • Each component of a vaccine (antigen, diluent/adjuvant) has a unique NDC.
  • Some GSK vaccines are provided in a vial or prefilled syringe presentation, each of which has a different NDC.
  • The outer carton or packaging of each vaccine has its own NDC—most payers recognize the outer carton for billing purposes.

When reporting NDCs per individual payer requirements, NDCs must be documented in an 11-digit format.1 The 11-digit NDC requirement is a 5-4-2 format. GSK vaccines typically have a 10-digit NDC, so a "0" would be added immediately after the first hyphen in the vaccine NDC.

On the CMS-1500 claim form (loop 2400 on the electronic claim form), the NDC may be added in Section 24 in the shaded area above "Date(s) of Service."1 When adding the NDC(s), make sure each begins with the “N4” qualifier identifying it as an NDC.1 Make sure you understand payer requirements for appropriate reporting of NDCs.

Questions?

Find answers to frequently asked questions, along with additional resources, to guide you to the information you need.

Get help

GSK Codes Summary Sheet

Get a PDF of the most current CPT, CVX, MVX, and NDC codes for GSK vaccines.

Download

References:

  1. Medicare claims processing manual chapter 26: completing and processing form CMS-1500 data set. Rev. 11037, 05-27-22. Centers for Medicare and Medicaid Services. Accessed September 1, 2023. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf
  2. When is it appropriate to report an evaluation & management service during immunization administration? American Academy of Pediatrics. Accessed September 1, 2023. https://downloads.aap.org/AAP/PDF/AAP%20Position%20Paper%20EM%20IA.pdf
  3. NDC crosswalk tables. Centers for Disease Control and Prevention. Accessed September 1, 2023. https://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_crosswalk.asp