CPT 90380 RSV Monoclonal Antibody Reimbursement | OpenPayer

Summary & Overview

CPT 90380: RSV Monoclonal Antibody, 0.5 mL Intramuscular Dose

CPT code 90380 designates a monoclonal antibody administered intramuscularly to provide seasonal protection against respiratory syncytial virus (RSV). As a targeted passive immunoprophylaxis product delivered as a 0.5 mL dose, this code is relevant for outpatient immunization services, particularly in pediatric and high-risk adult populations during RSV season. Nationally, use of RSV monoclonal antibodies has implications for prevention strategies, supply management, and payer coverage policies.

Key payers discussed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for 90380, typical sites of service, and the service type. The publication summarizes coverage considerations, common billing modifiers, and where data was available or not. It also outlines benchmark and policy topics relevant to payers and providers, helping stakeholders understand how 90380 fits into seasonal immunization workflows and claim submission practices.

What readers will learn: clinical description and intended use of the product coded by 90380, which payers are included in the coverage review, and a summary of the types of benchmarks and policy updates typically relevant to seasonal monoclonal antibody immunizations. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 90380RSV prophylaxismonoclonal antibodyimmunizationoutpatient servicespediatric immunizationseasonal doseinjectable therapybilling and coding

Billing Code Overview

CPT code 90380 represents a monoclonal antibody product administered intramuscularly to provide passive protection against respiratory syncytial virus (RSV). The product is supplied as a seasonal dose with a volume of 0.5 mL.

Service type: Immunization / Passive Immunoprophylaxis

Typical site of service: Outpatient clinic or ambulatory care setting, including pediatric clinics and specialized immunization centers.

Clinical & Coding Specifications

Clinical Context

A full-term or preterm infant or high-risk pediatric patient presents during RSV season for administration of passive immunoprophylaxis. The patient is scheduled for a single intramuscular injection of a monoclonal antibody product, 0.5 mL dose, to provide protection against respiratory syncytial virus (RSV). Typical settings include outpatient pediatric clinics, primary care offices, community health centers, and hospital-based outpatient infusion or immunization clinics. The clinical workflow includes verification of patient eligibility and dosing history, informed consent from the parent or guardian, review of allergies and prior adverse reactions, preparation of the 0.5 mL intramuscular dose, administration into the anterolateral thigh for infants or deltoid for older children, observation for acute adverse reactions for 15–30 minutes, documentation of lot number and expiration, and billing using 90380 for the seasonal intramuscular monoclonal antibody RSV prophylaxis dose. Common payors include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare for coverage adjudication and benefit verification prior to service.

Coding Specifications

Modifier	Description	When to Use
`00`	Default unmodified code	Use when no modifier applies and service is billed routinely.

CPT 90382: RSV Monoclonal Antibody Intramuscular Injection, 0.7 mL

CPT-90281-IMMUNOGLOBULIN-THERAPY-INFUSION

CPT 90281: Immunoglobulin Therapy, Passive Immunity

CPT-90378-RSV-IMMUNE-GLOBULIN-INTRAMUSCULAR

CPT 90378: Respiratory Syncytial Virus Immune Globulin, Intramuscular

CPT-90396-VARICELLA-ZOSTER-IMMUNE-GLOBULIN-IMMUNOPROPHYLAXIS

CPT 90396: Intramuscular Varicella–Zoster Immune Globulin Supply

CPT-90389-TETANUS-IMMUNOGLOBULIN-PASSIVE-IMMUNIZATION

CPT 90389: Tetanus Immunoglobulin for Passive Immunization

CPT-90377-RABIES-IMMUNOGLOBULIN-HUMAN-HIGH-TITER

CPT 90377: Human Rabies Immunoglobulin, High-Titer

CPT-90371-HEPATITIS-B-IMMUNOGLOBULIN-HBIG

CPT 90371: Hepatitis B Immunoglobulin (HBIg)

CPT-90393-VACCINE-IMMUNE-GLOBULIN-SMALLPOX-PROPHYLAXIS

CPT 90393: Vaccine Immune Globulin for Smallpox Prophylaxis

CPT-90399-IMMUNE-GLOBULIN-ADMINISTRATION-UNLISTED

CPT 90399: Immune Globulin Administration, Unlisted

CPT-90288-BOTULISM-IMMUNE-GLOBULIN-INTRAVENOUS

CPT 90288: Botulism Immune Globulin Intravenous

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Taxonomy Code	Specialty	Notes
207Q00000X	Pediatric Medicine	Most common specialty administering RSV prophylaxis to infants and young children.
207RH0000X	Family Medicine	Provides immunizations and outpatient prophylaxis in community settings.
207K00000X	Internal Medicine-Pediatrics	Cares for children in practices that deliver immunizations and prophylaxis.
363A00000X	Nurse Practitioner (Pediatrics)	NP clinicians frequently administer and document vaccine/prophylaxis services.
363L00000X	Registered Nurse	RNs commonly perform preparation, administration, and observation under standing orders.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Primary diagnosis code used when administering prophylactic monoclonal antibody for RSV.
`P07.3`	Preterm newborn, gestational age 28-31 completed weeks	High-risk infants born preterm are typical candidates for RSV prophylaxis.
`P07.2`	Preterm newborn, gestational age 32-33 completed weeks	Preterm infants in this gestational range may meet criteria for prophylaxis depending on comorbidities.
`J96.00`	Acute respiratory failure, unspecified whether with hypoxia or hypercapnia	Used if patient has recent severe pulmonary disease increasing RSV risk; indicates clinical relevance if prophylaxis considered.
`Q21.1`	Atrial septal defect	Congenital heart disease codes such as this indicate higher RSV hospitalization risk and potential indication for prophylaxis.
`I50.1`	Left ventricular failure	Cardiac disease in infants/children that raises risk for severe RSV and may support prophylaxis decisions.
`Z91.19`	Patient's other noncompliance with medical treatment and regimen, unspecified	Documentation code only when relevant to prophylaxis scheduling or missed doses.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96372`	Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular)	Commonly used for separate billing of IM injection administration when facility or payer requires distinct administration code alongside drug code.
`90471`	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular) when given alone	Used to bill administration of an immunization when the payer requires the immunization administration code rather than an injection code.
`90472`	Each additional concurrent immunization administration	Used if multiple vaccines or prophylactic agents are administered during the same encounter.
`99070`	Supplies and materials provided by physician over and above those usually included with the office visit	Used when additional supplies (special syringes, disposal) are billed per payer policy.
`90460`	Immunization administration for counseling and vaccine to patient under 18, first antigen	Used in scenarios where counseling and administration are reported for a pediatric patient, per payer guidance.

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