M1065 Shingrix Non-Admin | HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1065: Shingrix Vaccine Not Administered, Documented Reason

HCPCS Level II code M1065 denotes that the Shingrix vaccine was not administered and that the reason is documented by the clinician. This code captures clinically relevant circumstances such as patient allergy or medical contraindication, patient refusal, administration of a different vaccine, or supply and system limitations. Nationally, consistent use of this code improves immunization records, supports quality measurement, and clarifies vaccine delivery gaps across outpatient care settings. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical meaning, typical sites of service, and the policy and billing context that affects reporting and claims processing. The publication summarizes common modifiers and stakeholder considerations, highlights how the code is used in practice for documentation and quality tracking, and identifies where input was unavailable. Data not available in the input is noted where applicable. This resource is aimed at billing managers, compliance officers, clinicians, and policy analysts seeking a clear, national-level explanation of HCPCS Level II code M1065 and its role in vaccine documentation workflows.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1065HCPCS Level IIShingrixvaccine documentationimmunization billingoutpatient servicesvaccine refusalsupply issuesquality reporting

Billing Code Overview

HCPCS Level II code M1065 indicates that the Shingrix vaccine was not administered for reasons documented by the clinician. Examples of acceptable documentation include: the patient received a vaccine other than Shingrix, the patient had an allergy or other medical contraindication, the patient declined vaccination or cited other personal reasons, or the vaccine was not available due to system or supply issues.

Service type: Vaccine administration decision/documentation reflecting non-administration of Shingrix
Typical site of service: Outpatient settings where adult immunizations are provided, such as primary care clinics, specialty clinics, pharmacies, and community health centers

Clinical & Coding Specifications

Clinical Context

A 68-year-old patient presents to a primary care clinic for routine preventive care and is due for herpes zoster vaccination. The clinician reviews immunization history and documents that the patient already received an alternative shingles vaccine at a pharmacy two weeks prior. The clinician records the reason the Shingrix vaccine was not administered and updates the chart. The practice bills HCPCS Level II code M1065 to indicate that the Shingrix vaccine was not given, with the clinician-documented reason (patient received another vaccine, patient allergy, patient declined, vaccine supply issue, or other medical/system reason). Typical workflow steps include verification of prior immunization, counseling and documentation of patient decision or contraindication, updating the electronic health record immunization field, and submission of the non-administration code M1065 with appropriate visit-level CPT or E/M codes as applicable.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional work is documented beyond typical counseling or documentation associated with non-administration (rare for vaccine non-administration).

HCPCS Level II M1036: Adults Without 180 Days Continuous OUD Pharmacotherapy

HCPCS-M1026-HOSPICE-STATUS-ANY-TIME-DURING-PERFORMANCE-PERIOD

HCPCS M1026: Patients in Hospice During Performance Period

HCPCS-M1017-PALLIATIVE-CARE-ADMISSION

HCPCS Level II M1017: Patient Admitted to Palliative Care Services

HCPCS-M1009-DISCHARGE-EPISODE-OF-CARE

HCPCS M1009: Discharge/Discontinuation of Episode of Care

HCPCS-M1014-DISCHARGE-EPISODE-OF-CARE-DOCUMENTATION

HCPCS M1014: Discharge/Discontinuation of Episode of Care

HCPCS-M1053-LEG-PAIN-VAS-PREOP-POSTOP-ASSESSMENT

HCPCS M1053: Leg Pain VAS Preoperative and One-Year Postoperative Assessment

HCPCS-M1025-HOSPICE-ENROLLMENT-DURING-PERFORMANCE-PERIOD

HCPCS Level II M1025: Patients Enrolled in Hospice During Performance Period

HCPCS-M1023-ADOLESCENT-DEPRESSION-REMISSION-6-MONTHS

HCPCS M1023: Adolescent Depression Remission at Six Months

HCPCS-M1060-PATIENT-DIED-PRIOR-TO-PERFORMANCE-PERIOD

HCPCS M1060: Patient Died Prior to End of Performance Period

HCPCS-M1006-DISEASE-ACTIVITY-NOT-ASSESSED

HCPCS Level II M1006: Disease Activity Not Assessed, Reason Not Given

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians commonly document vaccine non-administration and bill `M1065`.
`208D00000X`	General Internal Medicine	Internists routinely manage adult vaccination status and document reasons for non-administration.
`207RC0000X`	Preventive Medicine	Preventive care specialists document vaccine counseling and immunization decisions.
`3336C0002X`	Pharmacy	Pharmacists administer and document vaccinations; they may also record that Shingrix was not given for specific reasons.
`363L00000X`	Nursing	Registered nurses often document immunization refusal or contraindication and support billing workflows.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z28.1`	Immunization not carried out because of contraindication	Used when a documented medical contraindication prevents administration of Shingrix and `M1065` is reported.
`Z28.2`	Immunization not carried out because of patient decision for reasons of belief or refusal	Used when the patient declines Shingrix and non-administration is documented with `M1065`.
`Z28.89`	Other specified reasons for not receiving immunization	Used for system or other specified reasons (vaccine not available, scheduling issues) when reporting `M1065`.
`Z23`	Encounter for immunization	Used as a supporting code when the visit is for immunization services even if Shingrix is not administered.
`T78.2XXA`	Anaphylactic shock, unspecified, initial encounter	Relevant when a documented allergy or prior anaphylaxis is the reason for not administering Shingrix; used with caution and appropriate sequencing.
`Z91.1`	Patient's noncompliance with medical treatment and regimen	Used when patient behavior or non-adherence contributes to vaccine not being given and documentation supports this reason.
`R68.89`	Other general symptoms and signs	May be used when acute symptoms at presentation lead to temporary deferral of vaccination, documented alongside `M1065`.
`Z74.09`	Other reduced mobility	Relevant when mobility or access issues are a patient-related reason for non-administration and documented in the record.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Common visit code during which the decision or documentation that Shingrix was not administered is recorded; billed for the clinician encounter.
`90460`	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine	Not directly used for adult Shingrix non-administration but may appear in charting when immunization services are discussed; include only when administration occurs during the visit.
`90471`	Immunization administration (per vaccine) by intramuscular, intranasal, oral or subcutaneous route; first or only component of each vaccine	Related when the vaccine is administered; absent when `M1065` indicates non-administration.
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Example of additional counseling services that may be billed during the same visit when vaccine counseling occurs.
`G0008`	Administration of influenza vaccine, for administration of influenza vaccine to Medicare beneficiaries	Example of a vaccine administration code used in the same clinical practice; provides context for immunization workflows when Shingrix is not given.

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