M1176 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1176: Incomplete Herpes Zoster Recombinant Vaccine Series

HCPCS Level II code M1176 records an incomplete two-dose primary series of the herpes zoster recombinant vaccine when the second dose was not received at least 28 days after the first between October 20, 2017, and the end of the measurement period. Nationally, this measure matters for immunization quality reporting, population health tracking, and adherence monitoring for shingles prevention. It flags patients who may be at continued risk due to incomplete vaccination and can affect quality metrics and reporting for outpatient and preventive care programs.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code's clinical meaning, typical service settings, and its role in immunization reporting. The publication summarizes how the code is used in documentation and quality measurement, outlines common billing considerations, and provides context for benchmarking and policy review. Data on modifiers, associated taxonomies, ICD-10 diagnoses, related codes, and detailed service-line information are not present in the input. The content is intended for national audiences interested in coding accuracy, immunization program performance, and administrative reporting related to herpes zoster vaccination.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1176HCPCS Level IIherpes zoster vaccineimmunizationvaccination adherencepreventive careoutpatient servicesquality measurement

Billing Code Overview

HCPCS Level II code M1176 indicates that the patient did not receive two doses of the herpes zoster recombinant vaccine (at least 28 days apart) on October 20, 2017, through the end of the measurement period. This code documents an incomplete two-dose primary series for the recombinant zoster vaccine during the specified measurement timeframe.

Service type: Vaccination record / Immunization follow-up

Typical site of service: Outpatient immunization or clinic setting, including primary care offices, specialty clinics, and community vaccination sites where zoster vaccination is administered and documented.

Clinical & Coding Specifications

Clinical Context

A 68-year-old patient presented to a primary care clinic on October 20, 2017, for routine preventive care and discussion of herpes zoster vaccination. The patient received the first dose of the herpes zoster recombinant vaccine (Shingrix) during that visit but did not return for the second dose within the recommended minimum interval of 28 days. Clinical workflow steps included documentation of vaccine administration in the electronic health record (EHR), scheduling a follow-up appointment and vaccine reminder, review of contraindications and allergies, and reconciliation of immunization history. The episode spans from the initial dose on 2017-10-20 through the end of the measurement period, with the outcome that the patient did not complete the two-dose series by the close of the measurement window. Typical sites of service include an outpatient primary care clinic or community vaccination clinic. Common clinical staff involved are a primary care physician or advanced practice provider, nursing staff who administer vaccines, and care coordination staff who manage recall and reporting to immunization registries.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work or resources for counseling/documentation related to vaccine series are substantially greater than typical.

HCPCS Level II M1484: No Repeat HCV RNA Labs, Medical Reason

HCPCS-M1293-BMI-ELEVATED-FOLLOW-UP-PLAN-DOCUMENTED

HCPCS Level II M1293: Elevated BMI with Follow-Up Plan Documented

HCPCS-M1346-PAM-NO-NET-INCREASE-4-12-MONTHS

HCPCS Level II M1346: No Net PAM Score Increase (4–12 Months)

HCPCS-M1237-PATIENT-REASON-NOT-SCREENING-SOCIAL-NEEDS

HCPCS M1237: Patient Reason for Not Completing Social Needs Screening

HCPCS-M1374-RA-ADDITIONAL-ENCOUNTER-90-DAYS

HCPCS M1374: Additional Rheumatoid Arthritis Encounter, 90+ Days

HCPCS-M1421-DERMATOLOGY-MIPS-VALUE-PATHWAY

HCPCS Level II M1421: Dermatology MIPS Value Pathway

HCPCS-M1319-CSP-CONTACT-AFTER-POSITIVE-HRSN-SCREENING

HCPCS M1319: CSP Contact After Positive High-Risk Screening

HCPCS-M1390-MELANOMA-RECURRENCE-EXAM-NOT-DOCUMENTED

HCPCS Level II M1390: Missing Exam for Melanoma Recurrence

HCPCS-M1440-TELEHEALTH-ENCOUNTER-VIRTUAL-VISIT

HCPCS M1440: Telehealth Encounter

HCPCS-M1232-HCV-ANTIBODY-TEST-REACTIVE-RESULT

HCPCS M1232: HCV Antibody Test, Reactive Result

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary clinicians who commonly initiate and administer adult vaccines.
`207R00000X`	Internal Medicine	Primary care internists who administer adult immunizations.
`363A00000X`	Nurse Practitioner	Advanced practice providers who commonly provide vaccine counseling and administration.
`363L00000X`	Physician Assistant	Clinician extenders frequently performing vaccine administration in outpatient settings.
`261QM0800X`	Public Health Nurse	Nursing staff in community vaccination clinics and public health programs.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Primary diagnosis code used to indicate a visit for vaccine administration and tracking of immunization status.
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Used when vaccine administration occurs as part of a routine preventive exam.
`Z28.3`	Encounter for prophylactic vaccination and inoculation against shingles	Used specifically to indicate shingles vaccination encounter and series status.
`Z91.128`	Patient's other noncompliance with medical treatment and regimen	May be used when the patient did not return for the second dose of a scheduled vaccine series.
`J30.9`	Allergic rhinitis, unspecified	Represents allergic history that may be reviewed prior to vaccination to assess contraindications.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90471`	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); single vaccine/toxoid	Used for administration of a single vaccine dose when billed separately from vaccine product cost.
`90472`	Each additional vaccine/toxoid administered (List separately in addition to code for primary procedure)	Used when multiple vaccine products are administered at the same visit in addition to the primary vaccine.
`90460`	Immunization administration through 18 years of age via permanent catheter, percutaneous, intramuscular or subcutaneous route requiring complex documentation (includes counseling)	Not typically used for adult herpes zoster immunization but listed when counseling and complex administration documentation occur for younger patients.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M code for a visit where vaccine counseling and administration are performed.
`99401`	Preventive medicine counseling, individual, approximately 15 minutes	Used when vaccine counseling is provided as a distinct preventive counseling service during the visit.

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