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    OpenPayerBilling CodesOther ServicesHCPCS hcpcs-m1178-documentation-pneumococcal-vaccine-exemption
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    HCPCS Level II M1178: Documentation of Medical Reason for Not Administering Pneumococcal Vaccine

    HCPCS Level II code M1178 documents the medical reason(s) for not administering pneumococcal vaccine (for example, prior anaphylaxis to the pneumococcal vaccine) and is used to record vaccine refusal for clinical/medical contraindications during vaccine assessment and counseling; typical sites of service include outpatient clinics, primary care offices, and immunization clinics where pneumococcal vaccination would otherwise be indicated.

    For related coverage guidance, see recent payer policy updates: Interferential Stimulation Devices (for home use), Durable Medical Equipment (DME): Tumor Treating Fields (Alternating Electric Field Therapy) Medical Guideline, Durable Medical Equipment (DME): Bone Growth Stimulators Medical Guideline.

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    Clinical & Coding Specifications

    Clinical Context

    A 68-year-old patient presents to a primary care clinic for routine preventive care during influenza season. The patient has a documented history of prior anaphylaxis to a pneumococcal vaccine component after a childhood vaccination, recorded in the electronic medical record. The clinician reviews the immunization history, assesses current contraindications and patient allergy details, and documents the medical reason for not administering the pneumococcal vaccine. Clinic staff attach the patient’s prior allergy record and the clinician’s note to the visit documentation. The service is billed using M1178 to indicate documentation of medical reason(s) for not administering pneumococcal vaccine. Typical workflow includes: patient intake and allergy review, clinician evaluation and counseling, explicit documentation of the contraindication or medical reason in the chart, and coding/billing using M1178 on the outpatient claim. Typical sites of service include an outpatient clinic, primary care office, community health center, or long-term care facility where vaccine assessment and documentation occur.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    90471Immunization administration (single vaccine) intramuscular or subcutaneousPerformed when the pneumococcal vaccine is administered; ineligible if M1178 documents medical reason for non-administration.
    90472Each additional vaccine administration (same visit)Used when multiple vaccines are given in the same visit; not used if pneumococcal vaccine is declined or contraindicated and only other vaccines are administered.
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesCommon E/M code used for the visit during which vaccine contraindication is assessed and documented alongside M1178.
    99214Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutesUsed when the visit requires moderate complexity documentation about vaccine history, allergies, and counseling.
    G0365Professional services for influenza vaccine administration (physician service under Medicare)Example of a vaccine-related Medicare code; used for vaccine administration encounters in the same workflow when administration occurs.

    Related Modifiers

    7 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    207Q00000XFamily Medicine PhysicianFamily Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
    207R00000XInternal Medicine PhysicianA physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
    207K00000XAllergy & Immunology PhysicianAn allergist-immunologist is trained in evaluation, physical and laboratory diagnosis, and management of disorders involving the immune system. Select…
    363L00000XNurse Practitioner(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision mak…
    367A00000XAdvanced Practice MidwifeAdvanced practice midwifery encompasses the independent provision of care during pregnancy, childbirth, and the postpartum period; sexual and reproduc…
    261QM1300XMulti-Specialty Clinic/CenterAmbulatory Health Care Facilities · Clinic/Center
    261QR1300XRural Health Clinic/CenterAmbulatory Health Care Facilities · Clinic/Center
    2080B0002XPediatric Obesity Medicine PhysicianA physician who specializes in the treatment of obesity demonstrates competency in and a thorough understanding of the treatment of obesity and the ge…

    Related ICD-10-CM Codes

    27 rows

    ICD-10-CM CodeDescription
    B20Human immunodeficiency virus [HIV] disease
    D63.8Anemia in other chronic diseases classified elsewhere
    D65Disseminated intravascular coagulation [defibrination syndrome]
    D69.6Thrombocytopenia, unspecified
    E86.0Dehydration
    J11.1Influenza due to unidentified influenza virus with other respiratory manifestations
    J18.9Pneumonia, unspecified organism
    L50.0Allergic urticaria
    N18.9Chronic kidney disease, unspecified
    R50.9Fever, unspecified

    Showing 1–10 of 27

    Related Payer Policy Updates

    Specialty: Durable Medical Equipment (DME)1 / 2

    5 rows

    PolicyPayerEffective Date
    Interferential Stimulation Devices (for home use)Moda Health2026-10-01
    Durable Medical Equipment (DME): Tumor Treating Fields (Alternating Electric Field Therapy) Medical GuidelineWPS Health Insurance2026-10-01
    Durable Medical Equipment (DME): Bone Growth Stimulators Medical GuidelineWPS Health Insurance2026-10-01
    General Durable Medical Equipment (DME) Medical GuidelineWPS Health Insurance2026-10-01
    Prior Authorization for Durable Medical Equipment (DME)Blue Cross Blue Shield - Rhode Island2026-10-01

    Related Codes

    HCPCS-LEVEL-II-M1252-AMBULATORY-PALLIATIVE-CARE-SURVEY-NONCOMPLETION

    HCPCS M1252: Ambulatory Palliative Care Patient Experience Survey Incomplete

    HCPCS-LEVEL-II-M1255-POSITIVE-PREGNANCY-TEST-NON-OB-VISIT

    HCPCS Level II M1255: Visit with Positive Pregnancy Test, Not Established OB

    HCPCS-LEVEL-II-M1278-ELEVATED-BLOOD-PRESSURE-WITH-DOCUMENTED-FOLLOW-UP

    HCPCS Level II M1278: Elevated or Hypertensive Blood Pressure Reading Documented

    HCPCS-LEVEL-II-M1292-FRAILTY-WITH-ADVANCED-ILLNESS-66-PLUS

    HCPCS M1292: Frailty with Advanced Illness, Age 66 and Older

    HCPCS-LEVEL-II-M1300-INFLUENZA-IMMUNIZATION-NOT-ADMINISTERED

    HCPCS Level II M1300: Influenza Immunization Not Administered, Documented Reason

    HCPCS-LEVEL-II-M1326-HYPOTONY-EVALUATION-MANAGEMENT

    HCPCS Level II M1326: Patients with a Diagnosis of Hypotony

    HCPCS-LEVEL-II-M1356-PATIENTS-WHO-DIED-DURING-MEASUREMENT-PERIOD

    HCPCS Level II M1356: Patients Who Died During Measurement Period

    HCPCS-LEVEL-II-M1375-RA-ADDITIONAL-ENCOUNTER-90-DAYS

    HCPCS Level II M1375: Additional Rheumatoid Arthritis Encounter

    HCPCS-LEVEL-II-M1384-PATIENTS-DIED-PERFORMANCE-PERIOD

    HCPCS Level II M1384: Patient Death During Performance Period

    HCPCS-LEVEL-II-M1490-PATIENT-STATUS-NOT-DOCUMENTED

    HCPCS Level II M1490: Patient Status Not Documented

    Showing 1–10 of 356

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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