M1175 HCPCS: Zoster Vaccine Reimbursement & Policy | OpenPayer

Summary & Overview

HCPCS Level II M1175: Documentation of Medical Reason for Not Administering Zoster Vaccine

HCPCS Level II code M1175 captures documentation of a medical reason for not administering the zoster vaccine, such as a prior anaphylactic reaction to the vaccine. This code supports accurate clinical records and billing when a vaccine is medically contraindicated or deferred for documented medical reasons. Nationally, standardized documentation using M1175 helps payers and providers distinguish medically necessary non-administration from simple refusals, which can affect coverage workflows and quality measurement.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of how the code is used in clinical workflows, typical sites of service, and the administrative context for claims processing. The publication also outlines expected benchmarks and policy considerations relevant to vaccine documentation codes, summarizes common modifiers associated with services around vaccine administration, and situates M1175 within immunization record-keeping practices.

This summary is written for a national audience and provides a practical reference for coding managers, clinicians, and billing teams responsible for documenting and submitting claims when the zoster vaccine is medically contraindicated or otherwise not given for documented medical reasons.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1175HCPCS Level IIzoster vaccinevaccine contraindicationimmunization documentationoutpatient servicesvaccine refusal documentation

Billing Code Overview

HCPCS Level II code M1175 documents the medical reason(s) for not administering zoster vaccine, for example prior anaphylaxis to the zoster vaccine. Its primary service type is vaccine refusal/contraindication documentation or clinical documentation related to immunization decision-making. The typical site of service is outpatient clinics or physician offices where vaccine assessment and counseling occur, including primary care and specialty practices that evaluate vaccine contraindications.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a community-dwelling adult age 50 years or older who presents to a primary care clinic, pharmacy-based immunization clinic, or outpatient specialty clinic (e.g., dermatology or rheumatology) for zoster vaccination counseling. During the visit the clinician reviews immunization history, current medications, allergy history, and immunocompetence. The patient declines or is determined ineligible for the zoster vaccine because of a documented medical contraindication (for example, prior anaphylaxis to a zoster vaccine component), acute moderate or severe illness, current high-dose immunosuppressive therapy, recent receipt of another live vaccine (for live zoster formulations), or other specified medical reasons. The clinician documents the medical reason(s) for not administering the zoster vaccine in the medical record and may provide alternative counseling or schedule future follow-up.

Typical workflow:

Patient check-in and medication/allergy reconciliation.
Clinical evaluation by nurse or clinician including review of immunization history and assessment for contraindications.
Shared decision discussion; clinician documents the specific medical reason(s) for non-administration and signs the note.
Coding and billing staff assign HCPCS Level II code M1175 for documentation of medical reason(s) for not administering the zoster vaccine and append appropriate modifiers as needed for payer reporting and claims adjudication.

Typical site of service: outpatient primary care clinic, ambulatory care clinic, pharmacy immunization site, or specialty outpatient clinic.

Coding Specifications

HCPCS Level II M1362: Patients Who Died During the Measurement Period

HCPCS-M1204-INITIAL-SYMPTOM-SEVERITY-ASSESSMENT-NRS-VRS-ITCHYQUANT

HCPCS M1204: Initial Symptom Severity Assessment (NRS/VRS/ItchyQuant)

HCPCS-M1461-CHRONIC-HEPATITIS-C-DIAGNOSIS

HCPCS M1461: Chronic Hepatitis C Diagnosis

HCPCS-M1376-RA-ADDITIONAL-ENCOUNTER-90-DAY-RULE

HCPCS Level II M1376: Additional RA Encounter, ≥90 Days

HCPCS-M1211-MOST-RECENT-HBA1C-GMI-OVER-9-0

HCPCS Level II M1211: Most Recent Glycemic Status Assessment >9.0%

HCPCS-M1269-ESRD-MCP-DIALYSIS-LAST-DAY-REPORTING-MONTH

HCPCS M1269: ESRD MCP Dialysis on Last Day of Reporting Month

HCPCS-M1149-NECK-PROM-UNABLE-TO-COMPLETE-DUE-TO-BARRIERS

HCPCS M1149: Neck PROM Not Completed Due to Patient Barriers

HCPCS-M1337-ACUTE-PERIPHERAL-VASCULAR-DISEASE

HCPCS M1337: Acute Peripheral Vascular Disease, Acute Care

HCPCS-M1445-POSTPARTUM-CARE-VISIT-12-WEEKS

HCPCS M1445: Postpartum Care Visit, Up to 12 Weeks

HCPCS-M1437-TELEHEALTH-ENCOUNTER

HCPCS M1437: Encounters Conducted via Telehealth

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Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional documentation supports substantially greater work than typical for vaccine counseling/decision-making that affects billing or payer review.
`23`	Unusual anesthesia	Not typically applicable to vaccine non-administration; included only when unusual sedation/anesthesia is documented and relevant.
`52`	Reduced services	Use when the service was partially reduced or not fully performed and documentation supports partial service.
`53`	Discontinued procedure	Use when the vaccination encounter was started but discontinued due to an acute contraindication documented in the record.
`54`	Surgical care only	Rarely applicable; include if only surgical care portion was provided by another provider in a multi-provider encounter.
`55`	Postoperative management only	Rarely applicable; use when only postoperative care is provided by another provider.
`56`	Preoperative management only	Use if another provider performed the preoperative portion of an encounter relevant to immunization clearance.
`62`	Two surgeons	Not typically applicable; include when two qualified practitioners share responsibility for the encounter.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Rare for immunization documentation; use only when applicable per payer rules.
`CO`	Casts or immobilization — used by some payers	Use per payer requirement when reporting care related to immobilization that affected vaccine administration.
`CQ`	Service furnished by a CRNA	Use when certified registered nurse anesthetist is involved and payer rules require reporting.
`FX`	Unlisted modifier for fracture care	Use only if a payer requires a fracture-related modifier that influenced vaccine non-administration.
`FY`	Unusual anesthesia modifier	Use per payer policy when unusual anesthesia is specifically documented and relevant.
`QK`	Medical direction of 2–4 concurrent anesthesia procedures	Use only if anesthesia medical direction is documented and relevant.
`QX`	CRNA service with medical direction by physician	Use if CRNA furnishes relevant services under physician direction affecting the encounter.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary site for vaccine counseling and documentation of reasons for non-administration.
`207R00000X`	Internal Medicine	Common specialty managing adult immunizations and contraindication documentation.
`363L00000X`	Pharmacist	Pharmacists often provide immunization counseling and document medical reasons for non-administration in pharmacy-based clinics.
`208000000X`	Pediatric Medicine	May document non-administration for age-appropriate patients transitioning to adult immunizations.
`207K00000X`	Geriatric Medicine	Frequently assesses older adults for zoster vaccination eligibility and documents contraindications.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Used when documenting immunization-related encounters; appropriate when counseling or documenting reasons for non-administration.
`T78.01`	Anaphylactic reaction due to food	Relevant when a history of anaphylaxis to vaccine components is documented as a contraindication; substitute specific allergen code as appropriate.
`T88.1`	Other complications following immunization, not elsewhere classified	Used when a patient has prior vaccine-related complications that justify non-administration.
`D70.9`	Neutropenia, unspecified	Represents an immunocompromised state that may contraindicate certain zoster vaccines; clinical relevance depends on vaccine type.
`Z92.25`	Personal history of vaccination against zoster	Documents prior vaccination status, which can influence the decision not to administer an additional dose.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90471`	Immunization administration (single vaccine)	Performed when vaccine is administered; contrasted with `M1175` which documents a medical reason for not administering the zoster vaccine.
`90472`	Immunization administration, each additional vaccine	Used when multiple vaccines are given during the same encounter; not used when zoster vaccine is not administered.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Common E/M code for the visit during which vaccine counseling and documentation of non-administration occur.
`99203`	Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity	Used for new patient encounters involving vaccine eligibility assessment and documentation of contraindication.
`99406`	Smoking and tobacco use cessation counseling, intermediate	Example ancillary counseling code that may be performed during the same visit; included as commonly paired preventive counseling.
`99401`	Preventive medicine counseling, individual	Preventive counseling codes that may be reported when counseling accompanies the decision not to vaccinate.

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