Summary & Overview
CPT 3216F: Documentation of Hepatitis B Immunity
CPT code 3216F is a supplemental tracking code indicating documented immunity to hepatitis B. As a non-procedural administrative code, it is used to capture verified serologic or documented immunization evidence that a patient is immune to hepatitis B. Nationally, tracking hepatitis B immunity supports public health surveillance, preventive care workflows, and accurate medical records for patient safety and vaccine management.
Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on where CPT code 3216F fits in clinical workflows, typical sites of service for documentation, and the role such supplemental tracking codes play in quality measurement and immunization registries. The publication also summarizes common use cases for recording hepatitis B immunity and highlights where data was not available in the input (for example, specific modifiers, associated taxonomies, ICD-10 pairings, or payer-specific coverage rules).
This summary is intended for a national audience of clinicians, billing professionals, and policy analysts seeking concise guidance on the clinical meaning and administrative purpose of CPT code 3216F, and what to expect when encountering this code in claims or medical records.
Billing Code Overview
CPT code 3216F indicates documentation that the patient has immunity to hepatitis B. This is a supplemental tracking code used to record verified hepatitis B immunity status in the medical record.
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Service type: Administrative/documentation of immunization status
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Typical site of service: Ambulatory clinic, primary care office, public health clinic, or any outpatient setting where immunization records and serologic status are reviewed or updated
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical outpatient preventive-care visit or occupational health encounter where a clinician documents a patient’s existing immunity to hepatitis B. The patient may present for a routine physical, school or employment health clearance, pre-procedure evaluation, or work-related exposure assessment. The workflow begins with review of past immunization records and laboratory results (such as hepatitis B surface antibody titers). The clinician confirms protective immunity based on documented complete vaccination series and/or positive anti-HBs serology, records the finding in the chart, and adds the supplemental tracking code 3216F to indicate documented immunity to hepatitis B. No vaccine administration is performed when 3216F is reported; it is used for tracking and quality reporting purposes and typically accompanies preventive service visit codes or occupational health visit codes in the medical record.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure | Use when an E/M visit is distinct from other services on the same day that result in documentation of hepatitis B immunity. |
59 | Distinct Procedural Service | Use when separating a procedure from unrelated services on the same day; rarely used with a supplemental tracking code but applicable when other same-day procedures exist.