M1171 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1171: Td or Tdap Vaccination Within Prior Nine Years

HCPCS Level II code M1171 documents that a patient received at least one Td or Tdap vaccine within the nine years preceding an encounter through the end of the measurement period. This code supports vaccination status tracking and quality measurement programs that monitor immunization coverage for tetanus-containing vaccines. Nationally, accurate capture of M1171 helps inform public health surveillance and payer reporting on preventive care.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, and how this code is used in claims to represent recent tetanus-containing immunization. The publication outlines expected use cases for ambulatory and outpatient settings, summarizes common modifiers when present (listed separately), and notes limitations where input data are not provided. The content is intended to clarify code meaning, billing context, and what elements are available for benchmarking and policy review at a national level.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1171HCPCS Level IITd vaccineTdap vaccineimmunizationpreventive carevaccination trackingoutpatient

Billing Code Overview

HCPCS Level II code M1171 indicates that a patient received at least one tetanus-diphtheria (Td) vaccine or one tetanus-diphtheria-acellular pertussis (Tdap) vaccine between nine years prior to the encounter and the end of the measurement period. The service type reflected by this code is vaccination / immunization administration tracking. The typical site of service for encounters captured by this code includes ambulatory care settings such as primary care clinics, pediatric offices, community health centers, and other outpatient vaccination sites.

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Clinical & Coding Specifications

Clinical Context

A middle-aged adult attends a primary care clinic for a routine preventive visit. The patient’s immunization history is reviewed and documentation shows they received either a tetanus-diphtheria (Td) vaccine or a tetanus-diphtheria-acellular pertussis (Tdap) vaccine within the window from nine years prior to the encounter through the end of the measurement period. The clinic nurse confirms vaccine lot number, administration site, and consent, and documents the immunization in the electronic medical record and state immunization registry. Billing staff assign HCPCS Level II code M1171 to indicate the patient received at least one Td or Tdap vaccine in the specified look-back period for quality measurement and reporting. Typical workflow steps include verification of prior immunization dates, patient education about booster timing, vaccine administration if needed, documentation of lot/expiration, and billing with applicable modifiers if circumstances require (for example, reporting discontinued services, unusual procedural circumstances, or specific payment conditions). Typical sites of service are outpatient primary care clinics, community health centers, school-based health clinics, and public health immunization clinics. Typical patient scenario: an adult presenting for an annual wellness visit whose chart shows a documented Tdap administered five years earlier during a prior hospitalization; the visit confirms the record, updates the immunization registry, and codes M1171 for the measurement period capture.

Coding Specifications

Modifier

HCPCS M1309: Palliative Care Services During Measurement Period

HCPCS-M1399-PATIENT-LEFT-PRACTICE-DURING-FOLLOW-UP

HCPCS M1399: Patient Leaves Practice During Follow-Up

HCPCS-M1398-PROMIS-BASELINE-FOLLOW-UP-SURVEYS

HCPCS Level II M1398: PROMIS Baseline and Follow-up Survey Documentation

HCPCS-M1196-INITIAL-ITCH-OR-SYMPTOM-SEVERITY-ASSESSMENT-NRS-VRS

HCPCS Level II M1196: Initial Itch/Symptom Severity Assessment (NRS/VRS/ItchyQuant)

HCPCS-M1435-ORAL-CHEMOTHERAPY-PATIENT-STATUS

HCPCS Level II M1435: Patient on Oral Chemotherapy

HCPCS-M1256-PRIOR-HISTORY-KNOWN-CVD

HCPCS M1256: Prior History of Known Cardiovascular Disease

HCPCS-M1491-ESRD-MCP-DIALYSIS-SERVICES

HCPCS Level II M1491: Receiving ESRD MCP Dialysis Services

HCPCS-M1152-HEART-TRANSPLANT-LVAD-PATIENT

HCPCS M1152: Heart Transplant or LVAD Patient

HCPCS-M1471-MEDICARE-PART-B-HEP-B-VACCINE-COVERAGE-STATUS

HCPCS M1471: Medicare Part B Hepatitis B Vaccine Coverage Status

HCPCS-M1274-SNF-ADMISSION-MONTHLY-EVALUATION-EXCLUSION

HCPCS Level II M1274: SNF Admission Monthly Evaluation Exclusion

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Most common specialty providing routine adult immunizations.
`207R00000X`	Internal Medicine	Primary care internists frequently document and administer Td/Tdap.
`208M00000X`	Pediatrics	Pediatric clinicians administer Tdap for adolescent and adult transition visits.
`363L00000X`	Public Health (Immunization Specialist)	Clinic and public health staff frequently deliver and document vaccines.
`335N00000X`	Nurse Practitioner	Nurse practitioners in outpatient and community settings commonly administer vaccines.

ICD-10 Code	Description	Clinical Relevance
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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 dose	Used when counseling and administration are billed for pediatric patients receiving the first vaccine dose in a visit.
`90461`	Immunization administration through 18 years of age, additional vaccine(s)	Used for additional vaccines administered to pediatric patients during the same visit.
`90471`	Immunization administration (single vaccine/toxoid) IM, SC; for adults and children	Commonly used for billing the administration of a single `Td` or `Tdap` vaccine in adult or pediatric patients.
`90472`	Immunization administration, each additional vaccine/toxoid (single syringe)	Used when multiple vaccines are given during the same encounter in addition to the primary vaccine.
`90714`	Tdap vaccine, for intramuscular use	Vaccine product code often billed by payers or recorded in inventory; links clinical administration to the vaccine product given.
`90703`	Tetanus and diphtheria toxoids (Td) vaccine, for intramuscular use	Product code for Td vaccine; relates to the service captured by `M1171` when Td is the recorded vaccine.

`22`	Increased procedural services	Use when extra work or time beyond typical administration is required and properly documented (rare for routine vaccination).
`23`	Unusual anesthesia	Use if general anesthesia or an unusual anesthesia circumstance is required (not typical for immunizations).
`52`	Reduced services	Use when vaccine administration was partially reduced or not fully performed as originally planned.
`53`	Discontinued procedure	Use if the vaccination procedure was started but discontinued for medical reasons.
`54`	Surgical care only	Not generally applicable to vaccines; included when only intraoperative care is billed by a surgeon.
`55`	Postoperative management only	Not generally applicable; used if only postoperative care is billed by a surgeon.
`56`	Preoperative management only	Not generally applicable; used if only preoperative care is billed by a surgeon.
`62`	Two surgeons	Use if two qualified practitioners were required and documented (very uncommon for vaccine administration).
`AS`	Non‑participating anesthesiologist	Use when a non-participating anesthesiologist provides services (not typical for vaccination).
`CO`	Cast application and removal	Not applicable to vaccinations; included among common modifiers list but not used for `M1171`.
`CQ`	Service furnished by a resident under graduate medical education	Use to indicate service was furnished by a resident when required by payer rules.
`FX`	Primary surgeon	Not applicable to vaccination; reserved for operative services.
`FY`	Regional managed care plan	Use to identify specific payer plan requirements if applicable.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures	Not applicable to routine vaccine administration.
`QX`	CRNA service with medical direction	Not applicable to vaccinations.

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