HCPCS M1179: Adult Pneumococcal Vaccine Not Received - OpenPayer

Summary & Overview

HCPCS M1179: Adult Pneumococcal Vaccine Not Received

HCPCS Level II code M1179 documents that an adult patient (age 19 or older) did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and within the measurement period. This administrative marker is used in quality measurement and immunization reporting to identify patients lacking recommended pneumococcal vaccination. Nationally, accurate capture of this status affects preventive care metrics and population health reporting for adult immunizations.

The analysis covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code's clinical context, typical sites of service, common billing modifiers (listed separately), and implications for reporting and quality measurement. The publication provides benchmarks where available, notes on policy updates relevant to adult pneumococcal vaccination capture, and guidance on interpreting the code within immunization and preventive care workflows. Data not available in the input for associated taxonomies, ICD-10 diagnoses, related codes, and service line are noted as such.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1179HCPCS Level IIpneumococcal vaccineadult immunizationpreventive carequality measurementvaccination statusoutpatient

Billing Code Overview

HCPCS Level II code M1179 indicates that a patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before or during the measurement period. This code documents absence of pneumococcal vaccination for adult patients during the specified time frame.

Service type: Vaccination status assessment / Immunization preventive service
Typical site of service: Primary care clinics, outpatient preventive care settings, community health centers, and other ambulatory care facilities

Data not available in the input for modifiers, associated taxonomies, ICD-10 diagnoses, related codes, and service line.

Clinical & Coding Specifications

Clinical Context

A 68-year-old male presents to a primary care clinic for an annual wellness visit. The patient’s medical record indicates he has not received any pneumococcal conjugate or polysaccharide vaccine on or after his 19th birthday and no documentation of pneumococcal immunization during the current measurement period. During the visit, the clinician reviews immunization history, discusses pneumococcal disease risk given the patient’s age and chronic obstructive pulmonary disease, and documents that no pneumococcal vaccine was administered. The clinical workflow includes verifying immunization registry and chart records, counseling reasons for vaccination or deferral, and recording the reason for nonadministration in the chart so the measure M1179 accurately reflects that the patient did not receive a pneumococcal vaccine during the measurement period. Typical documentation captures patient identifiers, immunization history query results, clinical rationale for nonvaccination, and any plan to vaccinate at a future encounter.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when documentation supports substantially greater work or complexity related to counseling or care coordination about immunizations beyond typical visit content.

HCPCS M1347: PAM Score Improvement Over 4–12 Months

HCPCS-M1387-PATIENT-DEATH-DURING-PERFORMANCE-PERIOD

HCPCS Level II M1387: Patient Death During Performance Period

HCPCS-M1251-PROXY-COMPLETED-HEALTH-SURVEY

HCPCS Level II M1251: Proxy-Completed Patient Health Survey

HCPCS-M1279-ELEVATED-BLOOD-PRESSURE-READING-NO-FOLLOW-UP-DOCUMENTED

HCPCS Level II M1279: Elevated Blood Pressure Reading, No Follow-Up Documented

HCPCS-M1441-INITIAL-SLEEP-APNEA-ENCOUNTER

HCPCS M1441: Initial Encounter for Sleep Apnea

HCPCS-M1429-RETINAL-EXAM-RETINOPATHY-WITH-SEVERITY-DOCUMENTED

HCPCS Level II M1429: Retinal Exam Finding with Retinopathy

HCPCS-M1277-COLORECTAL-CANCER-SCREENING-RESULTS-DOCUMENTED-REVIEWED

HCPCS Level II M1277: Colorectal Cancer Screening Results Documented and Reviewed

HCPCS-M1474-PATIENTS-WITH-DIAGNOSIS-OF-DEMENTIA

HCPCS M1474: Patients with Diagnosis of Dementia

HCPCS-M1288-DOCUMENTED-REASON-NOT-SCREENING-HIGH-BLOOD-PRESSURE

HCPCS M1288: Documented Reason for Not Screening or Recommending Follow-Up for High Blood Pressure

HCPCS-M1166-PATHOLOGY-REPORT-WIDE-LOCAL-EXCISION-REEXCISION

HCPCS M1166: Pathology Report for Wide Local Excision/Re-excision

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who routinely assess and document adult immunization status.
`208D00000X`	Internal Medicine	Adult medicine clinicians managing chronic disease and preventive care including pneumococcal vaccination.
`363L00000X`	Nurse Practitioner	Advanced practice providers who frequently administer and document vaccines in outpatient settings.
`1835A0400X`	Physician Assistant	PA providers delivering primary care and documenting immunization decisions.
`207K00000X`	Geriatric Medicine	Specialists managing older adults for whom pneumococcal vaccination is highly relevant.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Common visit diagnosis when reviewing preventive care and immunization status.
`Z23`	Encounter for immunization	Used when immunization is administered; when documenting nonreceipt, clinicians may still reference immunization status during this encounter.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	Chronic lung disease increases pneumococcal disease risk and is a frequent rationale to prioritize vaccination.
`I10`	Essential (primary) hypertension	Common comorbidity in adults being assessed for preventive care including pneumococcal vaccination.
`E11.9`	Type 2 diabetes mellitus without complications	Diabetes is an indication to consider pneumococcal vaccination in adult preventive planning.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90471`	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular) when performed	Commonly billed when a pneumococcal vaccine is administered; not used when `M1179` documents nonreceipt.
`90472`	Immunization administration, each additional vaccine (list separately in addition to primary)	Used when multiple vaccines are given during the same encounter; not applicable if no pneumococcal vaccine was given.
`99385`	Initial comprehensive preventive medicine evaluation, new patient; 18–39 years	Preventive visit codes often accompany immunization assessment; for older adults use age-appropriate initial codes (e.g., `99386`, `99387`).
`99396`	Periodic comprehensive preventive medicine reevaluation and management, established patient; 40–64 years	Preventive visit used for immunization review and counseling in established adults; documentation may support measure reporting.
`G0438`	Annual wellness visit, first visit	Medicare wellness visits frequently include immunization review and documentation relevant to `M1179`.

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