M1305 HCPCS Pneumococcal Vaccine Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1305: Adult Pneumococcal Vaccination

HCPCS Level II code M1305 captures administration of any pneumococcal conjugate or polysaccharide vaccine given to an individual aged 19 years or older within the measurement period. This preventive immunization code is used to document adult pneumococcal vaccination status for reporting and quality measurement. Nationally, pneumococcal vaccination is a key public health measure to reduce invasive pneumococcal disease, especially among older adults and those with chronic conditions.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what M1305 represents, where the service is typically delivered, and which payers commonly recognize the code. The publication outlines benchmark usage and reporting contexts, recent policy considerations affecting adult immunization documentation, and clinical context regarding pneumococcal vaccine types (conjugate and polysaccharide) relevant to adult care.

This summary provides a practical reference for coding, billing, and quality measurement staff seeking clear national-level context for M1305, including expected service settings and the role of the code in vaccination reporting and preventive care programs. Data not available in the input.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1305HCPCS Level IIpneumococcal vaccineadult immunizationpreventive carevaccination reportingquality measurement

Billing Code Overview

HCPCS Level II code M1305 documents that a patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period. This code represents vaccination administration for adults eligible for pneumococcal immunization.

Service type: Immunization administration for pneumococcal vaccine
Typical site of service: Outpatient clinics, community vaccination sites, primary care offices, and pharmacies

Clinical & Coding Specifications

Clinical Context

A 67-year-old patient presents to a primary care clinic during an annual wellness visit. The patient’s immunization record is reviewed and it is determined they are due for pneumococcal vaccination on or after their 19th birthday and within the measurement period. The nurse verifies prior pneumococcal vaccine history, screens for contraindications (severe allergic reaction to a previous pneumococcal vaccine component), and documents informed consent. The vaccine (either pneumococcal conjugate or polysaccharide) is administered intramuscularly in the deltoid; lot number, expiration date, manufacturer, route, site, and VIS (Vaccine Information Statement) date are recorded in the medical record and immunization registry. Billing is submitted using HCPCS Level II code M1305 to indicate receipt of any pneumococcal conjugate or polysaccharide vaccine administered on or after the patient’s 19th birthday during the measurement period. Typical workflow participants include the front-desk staff (scheduling and insurance verification), clinical nursing staff (screening, administration, documentation), and the ordering provider (review and authorization). Typical follow-up includes monitoring for immediate adverse reactions for 15 minutes and scheduling any required subsequent doses per CDC guidance.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when administration required substantially greater resources due to unusual circumstances (rare for vaccine administration).

HCPCS M1187: End Stage Renal Disease (ESRD) Care

HCPCS-M1473-ASSESSMENT-IMPACTING-FUNCTIONAL-MEASURE-VALIDITY

HCPCS M1473: Factors Affecting Validity of Functional/Cognitive Assessments

HCPCS-M1439-OCULAR-CONDITIONS-IMPACTING-VISUAL-OUTCOME-OF-SURGERY

HCPCS M1439: Significant Ocular Conditions Affecting Surgical Visual Outcome

HCPCS-M1409-BRCA-GENETIC-TESTING-OR-COUNSELING-WITHIN-6-MONTHS

HCPCS M1409: BRCA1/BRCA2 Germline Testing or Genetic Counseling within 6 Months

HCPCS-M1457-ASTHMA-DIAGNOSIS-DOCUMENTATION

HCPCS Level II M1457: Asthma Diagnosis Documentation

HCPCS-M1253-AMBULATORY-PALLIATIVE-CARE-PATIENT-DISAVOWAL

HCPCS M1253: Ambulatory Palliative Care Patient Disavowal

HCPCS-M1385-DOCUMENTATION-PAM-FOLLOW-UP-NONCOMPLETION

HCPCS M1385: Documentation of Reasons for Missed Second PAM Survey

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

HCPCS M1149: Neck PROM Not Completed Due to Patient Barriers

HCPCS-M1333-ACUTE-VITREOUS-HEMORRHAGE

HCPCS M1333: Acute Vitreous Hemorrhage

HCPCS-M1264-AGE-75-OR-OLDER-AT-DIALYSIS-INITIATION

HCPCS M1264: Patients Age 75 or Older at Dialysis Initiation

Showing 1–10 of 356

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Most common specialty administering adult pneumococcal vaccines in outpatient primary care.
`208D00000X`	Internal Medicine	Frequently provides adult immunizations during preventive and chronic care visits.
`363A00000X`	Nurse Practitioner	NPs commonly administer vaccines in primary care, urgent care, and community clinics.
`364S00000X`	Physician Assistant	PAs routinely provide vaccine administration and documentation in ambulatory settings.
`331K00000X`	Public Health Clinic	Public health nurses and immunization clinics frequently administer pneumococcal vaccines.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Primary diagnosis code commonly used to indicate an encounter for pneumococcal vaccination.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD is an indication for pneumococcal vaccination in adults at increased risk for pneumococcal disease.
`E10.9`	Type 1 diabetes mellitus without complications	Diabetes is a risk factor for invasive pneumococcal disease and often listed when vaccinating at-risk adults.
`I10`	Essential (primary) hypertension	Common comorbidity in adults receiving routine immunizations during primary care visits.
`D50.9`	Iron deficiency anemia, unspecified	Chronic medical conditions may be documented as comorbidities when administering vaccines to adults.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90471`	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular); single vaccine/dose	Used to report the act of administering a single pneumococcal vaccine dose when payer requires CPT administration reporting in addition to `M1305`.
`90472`	Immunization administration, each additional vaccine (single or combination vaccine/toxoid)	Used when a second or additional vaccine is administered during the same encounter.
`90460`	Immunization administration through 18 years of age via percutaneous, intradermal, subcutaneous, or intramuscular; with counseling by physician or other qualified health care professional, first component of 2 or more vaccines	Rarely used for adults; included here for workflow when counseling is separately reported and payer allows.
`90461`	Each additional vaccine or toxoid component administered (with counseling)	See `90460` for additional vaccine components counseling reporting.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M code when an established adult receives vaccine during a problem-focused or preventive visit and medical decision-making supports the visit complexity.

OpenPayer