M1168 Influenza Vaccine (HCPCS) Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1168: Seasonal Influenza Vaccination within Measurement Window

HCPCS Level II code M1168 documents that a patient received a seasonal influenza vaccine during the measurement window from July 1 of the year prior to the measurement period through June 30 of the measurement period. This preventive service code matters nationally because timely influenza immunization reduces community transmission and is a common quality measure used in payer performance programs and public health reporting.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find concise information on what the code represents, the clinical context for seasonal influenza immunization, typical sites of service, and how M1168 is used in measurement and reporting frameworks. The publication outlines common billing considerations and the role of this code in quality measurement and immunization tracking programs.

Data not available in the input is noted where applicable. The content is intended for national audiences seeking a clear, practical reference on HCPCS Level II code M1168 and its use in documenting influenza vaccination within defined measurement periods.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1168HCPCS Level IIinfluenza vaccineimmunizationpreventive caremeasurement periodoutpatient servicesquality measure

Billing Code Overview

HCPCS Level II code M1168 indicates that a patient received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period. This code is used to document seasonal influenza immunization administered within the specified measurement window.

Service type: Immunization administration for seasonal influenza
Typical site of service: Ambulatory settings such as primary care clinics, retail clinics, community vaccination events, and other outpatient sites where influenza vaccines are commonly given

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves an adult or pediatric patient presenting to a primary care clinic, family medicine practice, pediatric office, workplace occupational health clinic, pharmacy clinic, or community health center during influenza season. The patient is due for routine annual influenza immunization and receives the seasonal influenza vaccine administered intramuscularly (or intranasally for appropriate live-attenuated formulations) during an encounter that occurs on or between July 1 of the year prior to the measurement period and June 30 of the measurement period. The clinical workflow includes patient check-in, verification of vaccine eligibility and contraindications (allergies, history of Guillain-Barré, severe egg reaction if applicable), informed consent, vaccine preparation, administration of the vaccine, documentation of lot number/manufacturer/site/route, observation for immediate adverse reaction, updating the electronic medical record and immunization registry, and billing for the vaccine using HCPCS Level II code M1168 when applicable. Typical sites of service include outpatient clinic offices, retail pharmacies, workplace clinics, school-based clinics, and community health events.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS M1289: Tobacco User Without Cessation Intervention

HCPCS-M1223-GLAUCOMA-PLAN-OF-CARE

HCPCS M1223: Glaucoma Plan of Care Documented

HCPCS-M1382-OFFICE-PATIENT-ENCOUNTER-PLACE-OF-SERVICE-11

HCPCS M1382: Office Patient Encounter During Performance Period

HCPCS-M1406-PATIENTS-LEAVE-PRACTICE-DURING-FOLLOW-UP

HCPCS Level II M1406: Patients Who Leave Practice During Follow-Up

HCPCS-M1397-PATIENTS-RECURRENCE-DISEASE-PROGRESSION

HCPCS M1397: Patients with Recurrence/Disease Progression

HCPCS-M1411-FIRST-LINE-IMMUNE-CHECKPOINT-INHIBITOR-NO-CHEMOTHERAPY

HCPCS M1411: First-Line Immune Checkpoint Inhibitor Without Chemotherapy

HCPCS-LEVEL-II-M1503-VASCULAR-SURGERY-MIPS-VALUE-PATHWAY

HCPCS Level II M1503: Vascular Surgery MIPS Value Pathway

HCPCS-M1236-BASELINE-MODIFIED-RANKIN-SCALE-ABOVE-2

HCPCS M1236: Baseline Modified Rankin Scale > 2

HCPCS-M1180-IMMUNE-CHECKPOINT-INHIBITOR-THERAPY-MONITORING

HCPCS M1180: Patients on Immune Checkpoint Inhibitor Therapy

HCPCS-M1317-COUNSELING-CSP-CONNECTION-OPT-OUT

HCPCS M1317: Counseling on Community Service Provider Connection, Patient Opt-Out

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary setting for routine influenza vaccination
`207R00000X`	Internal Medicine	Adult immunizations commonly given in residency and adult primary care
`208000000X`	Pediatrics	Pediatric influenza vaccination and counseling
`3336C0003X`	Pharmacist	Pharmacists commonly administer vaccines in retail and clinic settings under state law
`363L00000X`	Public Health	Public health nurse and clinic programs providing community influenza immunization

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Primary diagnosis code used to indicate administration of an influenza vaccine
`J00`	Acute nasopharyngitis [common cold]	May appear if patient presents with mild upper respiratory symptoms; vaccination deferred if acutely ill per clinical judgment
`J10.1`	Influenza due to identified seasonal influenza virus with other respiratory manifestations	Indicates active influenza infection; vaccination not indicated during acute illness
`Z00.129`	Encounter for routine child health examination without abnormal findings	Preventive visit where influenza vaccination is commonly administered to pediatric patients
`Z71.89`	Other specified counseling	Used when specific vaccine counseling is provided and needs documentation

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90460`	Immunization administration through 18 years of age via any route, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered	Use when vaccine counseling and administration for pediatric patients requires separate coding for the first vaccine on the visit
`90461`	Each additional vaccine or toxoid administered to 18 years or younger, with counseling by physician or other qualified health care professional	Use for additional vaccines given during the same pediatric encounter
`90471`	Immunization administration (intramuscular, intradermal, subcutaneous) single vaccine; for patient of any age, first vaccine	Use for single influenza vaccine administration when not reporting age‑based codes or when payer requires per‑service CPT coding
`90472`	Each additional vaccine (same visit)	Use if more than one vaccine is given during the same visit
`90756`	Influenza virus vaccine, quadrivalent, split virus, preservative-free, for intramuscular use	Represents a common influenza vaccine product; may be reported in product documentation though HCPCS `M1168` is the billing code referenced
`90686`	Influenza virus vaccine, quadrivalent, recombinant, preservative-free, for intramuscular use	Common vaccine product code that may be used in clinical documentation when linking product to administration

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