G8867 Pneumococcal Vaccine — HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS G8867: Pneumococcal Vaccine Not Administered, Reason Not Given

HCPCS Level II code G8867 denotes that a pneumococcal vaccine was not administered and no reason was recorded. This status code is used in outpatient and ambulatory settings to document non-administration when the prior vaccination history or patient declination is not specified. Nationally, accurate use of this code affects immunization record completeness, quality reporting, and population-level vaccine uptake measurement.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context, common billing considerations, and how payers treat documentation of vaccine non-administration. The publication outlines benchmarks for documentation and reporting where available, summarizes relevant policy and coding guidance, and provides context for clinical workflows that involve vaccine offerings in ambulatory care.

This summary equips billing staff, clinicians, and compliance teams with concise information on the purpose of G8867, typical clinical settings where it is used, and the implications for immunization records and quality measurement. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG8867HCPCS Level IIpneumococcal vaccinevaccine documentationimmunization reportingambulatory carequality measurementbilling code

Billing Code Overview

HCPCS Level II code G8867 indicates pneumococcal vaccine not administered or previously received, reason not given. This code documents that a pneumococcal vaccine was not given to the patient and no specific reason was reported.

Service type: Vaccine administration/declination documentation
Typical site of service: Primary care clinic, outpatient clinic, or other ambulatory settings where immunizations are ordinarily offered

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult presenting to a primary care clinic or outpatient pharmacy during a routine visit for chronic disease management (for example, diabetes or chronic obstructive pulmonary disease). The provider reviews preventive immunizations and documents that the pneumococcal vaccine was not administered during the encounter and there is no documented prior receipt in the medical record. The clinical workflow includes: pre-visit medication and immunization reconciliation, vaccine eligibility assessment, shared decision-making discussion with the patient, and documentation in the electronic health record. The clinician selects billing code G8867 when the pneumococcal vaccine was not given and the reason for not administering the vaccine is not recorded. Typical sites of service include outpatient clinic exam rooms, community health centers, and ambulatory pharmacy settings. Common scenarios leading to use of G8867 include patient refusal without documented reason, missed opportunity when vaccine supply is unavailable and reason not entered, or oversight where administration was intended but not performed and no justification was recorded in the chart. This code communicates to payors that the vaccine was not provided and that no reason was documented at the time of the encounter.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS G9349: CT Scan of Paranasal Sinuses, Diagnostic Imaging

HCPCS-G8854-DOCUMENTATION-NONREPORTABLE-ADHERENCE-EVIDENCE-BASED-THERAPY

HCPCS G8854: Documentation of Non-Reportable Adherence to Evidence-Based Therapy

HCPCS-G0568-INITIAL-PSYCHIATRIC-COLLABORATIVE-CARE-MANAGEMENT

HCPCS G0568: Initial Psychiatric Collaborative Care Management

HCPCS-G9691-HOSPICE-SERVICES-DURING-MEASUREMENT-PERIOD

HCPCS G9691: Patient Received Hospice Services During Measurement Period

HCPCS-G8502-BACK-PAIN-QUALITY-MEASURES-COMPLETE

HCPCS G8502: Completion of Back Pain Quality Measures

HCPCS-G2181-BMI-NOT-DOCUMENTED-MEDICAL-REASON-OR-PATIENT-REFUSAL

HCPCS G2181: BMI Not Documented Due to Medical Reason or Patient Refusal

HCPCS-G9077-PROSTATE-CANCER-ADENOCARCINOMA-T1-T2C-GLEASON-2-7-PSA-LE-20

HCPCS G9077: Prostate Cancer Disease Status, Localized Adenocarcinoma

HCPCS-G0521-DEMENTIA-DYAD-MANAGEMENT-HIGH-COMPLEXITY

HCPCS G0521: Management of New Dementia Patient-Caregiver Dyad, High Complexity

HCPCS-G9918-FUNCTIONAL-STATUS-NOT-PERFORMED

HCPCS G9918: Functional Status Not Performed, Reason NOS

HCPCS-G0531-FACILITY-BASED-24-HOUR-RESPITE-UNIT-CMMI

HCPCS G0531: Facility-Based 24-Hour Respite Unit

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`208D00000X`	Family Medicine	Family physicians commonly assess immunization status and document vaccine non-administration.
`207Q00000X`	Internal Medicine	Internists provide preventive care for adults and document vaccine decisions.
`363LP0800X`	Ambulatory Pharmacy	Pharmacists in ambulatory settings often screen for vaccines and document administration or non-administration.
`207K00000X`	Pediatrics	Pediatricians assess pneumococcal vaccine status for eligible pediatric and young adult patients and document encounters.
`208000000X`	General Practice	General practitioners provide routine preventive care including immunization screening and documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Used to indicate vaccine-related encounter; relevant when documenting vaccine administration or refusal, and often paired with documentation of vaccine non-administration.
`Z28.3`	Encounter for underimmunization status	Indicates patient is not up to date on immunizations; relevant when pneumococcal vaccine was not given and immunization status is addressed.
`Z91.120`	Patient's intentional underdosing of medication regimen for other reason	May be used where patient refusal of vaccine is documented, though `G8867` denotes no reason recorded.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	Chronic respiratory disease that increases pneumococcal vaccine indication; relevant to encounters assessing vaccination needs.
`E11.9`	Type 2 diabetes mellitus without complications	Diabetes is an indication for pneumococcal vaccination; often present in patients evaluated for immunization.
`I10`	Essential (primary) hypertension	Common comorbidity found in adult patients during preventive care visits where vaccination status is reviewed.
`B20`	Human immunodeficiency virus disease	Immunocompromised patients have specific pneumococcal vaccination recommendations; relevant to vaccine decision-making.
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Preventive visit during which vaccine status is reviewed and `G8867` may be used if vaccine not given and no reason recorded.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90460`	Immunization administration through 18 years of age via any route; first vaccine/toxoid component, with counseling by physician or other qualified health care professional; with administration	Used when pneumococcal vaccine is administered with counseling during the same encounter; documents actual vaccine administration in pediatric populations.
`90471`	Immunization administration (single vaccine), subcutaneous or intramuscular	Commonly billed when pneumococcal vaccine is given to adults; contrasts with `G8867` which documents non-administration.
`90472`	Each additional vaccine component or single antigen administered in the same encounter	Used when multiple vaccines are given together; relevant when pneumococcal vaccine is administered alongside other immunizations.
`90473`	Immunization administration via intranasal or oral route; first vaccine/toxoid component	Relevant for other vaccines given by different routes, not for pneumococcal injection, but may appear in the workflow if other vaccines are administered.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M visit code during which vaccine assessment occurs and `G8867` may be reported if vaccine was not given and reason not documented.

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