Summary & Overview
HCPCS M1155: Anaphylaxis Due to Pneumococcal Vaccine, Documented
HCPCS Level II code M1155 identifies patients who experienced anaphylaxis related to the pneumococcal vaccine at any time during or before the measurement period. Nationally, accurate use of this code matters because it documents a serious vaccine adverse event and typically justifies exclusion from pneumococcal vaccination performance measures or triggers safety follow-up protocols. Proper coding supports patient safety tracking, quality measurement integrity, and appropriate claims processing.
Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Coverage policies and measure specifications across these payers influence how M1155 is applied for measure exclusions and data reporting.
Readers will learn the clinical context for using M1155, the typical service setting where the code is recorded, and what the code represents for quality measurement and claims documentation. The publication also summarizes benchmark and policy implications related to documenting vaccine anaphylaxis and where to look for payer-specific guidance. Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code M1155 indicates that the patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period. This code is used to document a documented severe allergic reaction to the pneumococcal vaccine.
Service type: Allergy/adverse reaction documentation and exclusion from vaccine measure
Typical site of service: Any site where vaccine history and adverse events are documented, including outpatient clinics, primary care offices, urgent care centers, and hospital-based clinics. Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient presents to a primary care clinic for routine immunizations and reports a past severe allergic reaction immediately following a pneumococcal vaccine administered within the last two years. The patient’s chart documents an episode meeting criteria for anaphylaxis (acute onset, respiratory compromise and hypotension) after pneumococcal vaccination. During the visit, the clinician reviews the history, documents the anaphylactic event, updates the problem list, and records vaccine contraindication status to prevent future pneumococcal immunization attempts. The workflow includes verification of prior vaccine administration and reaction details, entry of a documented contraindication in the electronic health record, communication of the contraindication in after-visit summaries, and coding of the encounter with the HCPCS Level II code M1155 to indicate patient had anaphylaxis due to pneumococcal vaccine any time during or before the measurement period. Typical sites of service are outpatient primary care clinics, urgent care centers, and allergy/immunology clinics. Common patient factors include prior immediate hypersensitivity to pneumococcal polysaccharide or conjugate vaccines, multiple comorbidities that increase vaccine scrutiny, and need for clear documentation for payors such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased Procedural Services |