Summary & Overview
HCPCS M1304: Adult Pneumococcal Vaccination Status Not Received
HCPCS Level II code M1304 denotes that an adult patient (age 19 or older) did not receive any pneumococcal conjugate or polysaccharide vaccine during the measurement period. The code is used to document vaccine status gaps in clinical records and quality measurement programs, making it relevant for population health reporting, immunization registries, and payer performance measures. Nationally, accurate capture of pneumococcal vaccination status affects preventive care metrics and pay-for-performance calculations tied to adult immunization rates.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on how M1304 is applied in clinical documentation and preventive-care workflows, what typical sites of service are involved, and how the code integrates into quality measurement frameworks. The publication summarizes common modifiers and related administrative details where available, highlights implications for reporting and registry submissions, and notes areas where input data was not provided. This overview is intended for a national audience of clinicians, billing professionals, and health policy analysts seeking concise guidance on the purpose and use of HCPCS Level II code M1304.
Billing Code Overview
HCPCS Level II code M1304 indicates that a patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period. This billing descriptor reflects a documented absence of pneumococcal vaccination within the specified adult measurement window.
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Service type: Preventive vaccine status assessment
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Typical site of service: Outpatient ambulatory care settings, primary care clinics, and preventive health visits
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient presents to a primary care clinic for an annual wellness visit. During medication reconciliation and preventive care review, the clinician identifies that the patient has not received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period. The clinical workflow includes verification of immunization history in the electronic health record, review of state immunization registry, discussion of pneumococcal vaccine benefits and contraindications, and documentation of refusal or plan for vaccination. If the patient consents, nursing staff administers the appropriate pneumococcal vaccine (PCV13, PCV15, PCV20, or PPSV23 depending on clinical indications and current recommendations), records lot number and administration site, and updates the record. If the patient declines or has contraindications, the clinician documents the reason and schedules follow-up as appropriate. The encounter is coded for quality measurement and reporting to capture that no pneumococcal vaccine was received during the measurement window, which informs population health outreach and preventive care metrics.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when documentation supports substantially increased physician work beyond typical for vaccine counseling or complex decision-making tied to immunization. |