M1419 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1419: Not Up to Date on COVID-19 Vaccinations

HCPCS Level II code M1419 identifies patients who are not up to date on COVID-19 vaccinations as defined by current CDC recommendations. Nationally, this code supports tracking of vaccination status for clinical care, reporting, and immunization outreach efforts during ongoing public health vaccination campaigns. The designation is relevant across ambulatory and public health settings where vaccination assessment or counseling occurs.

Key payers referenced for national consideration include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical intent, the typical service setting, and where this code fits into vaccination workflows. The publication summarizes payer coverage considerations, common billing modifiers, and how M1419 interacts with immunization documentation practices. It also outlines practical benchmarks and policy updates affecting immunization coding and reporting at a national level. The content is designed for billing professionals, clinical administrators, and policy analysts seeking clear context about use and implications of M1419 in routine immunization and public health activities.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1419HCPCS Level IICOVID-19 vaccinationimmunization statusvaccination assessmentoutpatient servicespublic health coding

Billing Code Overview

HCPCS Level II code M1419 denotes patients who are not up to date on their COVID-19 vaccinations as defined by CDC recommendations on current vaccination. The code is used to identify vaccination status for patients who have not received all CDC-recommended COVID-19 vaccine doses.

Service Type: Vaccination status assessment / immunization-related encounter

Typical Site of Service: Outpatient clinics, primary care offices, public health clinics, and vaccination sites

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves an adult or pediatric patient presenting to a primary care clinic, community health center, pharmacy-based immunization site, or public health clinic who is identified during triage or preventative care visit as not up to date on COVID-19 vaccination per CDC current recommendations. The clinical workflow begins with eligibility screening for contraindications and precautions (allergies, history of severe reaction to a prior dose, immunocompromise status), review of prior vaccine history and immunization registry, and counseling about current CDC-recommended vaccine formulation and dosing schedule. After documentation of informed consent and completion of necessary screening questions, the selected COVID-19 vaccine is prepared and administered via intramuscular injection. Post-vaccination observation is performed for the recommended period (typically 15–30 minutes) to monitor for immediate adverse reactions. Documentation includes the vaccine manufacturer, lot number, administration site, VIS date, consent, and billing code M1419 for patients not up to date per CDC recommendations. Typical sites of service are outpatient clinic, ambulatory surgery center (if bundled with other procedures), pharmacy vaccination clinic, and public health vaccination events. A realistic scenario: a 68-year-old patient with chronic obstructive pulmonary disease presents for an annual visit; review of the state immunization registry shows no COVID-19 booster in the past 12 months; after vaccine counseling and screening, the patient receives the recommended booster and observation in the clinic, and the encounter is billed using M1419 with appropriate ICD-10 diagnosis codes reflecting risk factors or need for immunization as applicable.

Coding Specifications

Modifier	Description

HCPCS M1482: Positive/Detectable Hepatitis C Virus RNA Test Result

HCPCS-M1155-ANAPHYLAXIS-PNEUMOCOCCAL-VACCINE

HCPCS M1155: Anaphylaxis Due to Pneumococcal Vaccine, Documented

HCPCS-M1242-PATIENT-DID-NOT-RESPOND-PATIENT-CENTEREDNESS-QUESTION

HCPCS M1242: Patient Nonresponse to Patient-Centeredness Question

HCPCS-M1354-SUICIDE-SAFETY-PLAN-NOT-INITIATED-OR-REVIEWED

HCPCS M1354: Suicide Safety Plan Not Initiated or Reviewed

HCPCS-M1160-MENINGOCOCCAL-VACCINE-ANAPHYLAXIS-BEFORE-AGE-13

HCPCS M1160: Anaphylaxis from Meningococcal Vaccine Before Age 13

HCPCS-M1218-COPD-SYMPTOM-EVALUATION

HCPCS M1218: COPD Symptom Evaluation and Management

HCPCS-M1420-COMPLETE-OPHTHALMOLOGIC-CARE-MIPS-VALUE-PATHWAY

HCPCS M1420: Complete Ophthalmologic Care MIPS Value Pathway

HCPCS-M1411-FIRST-LINE-IMMUNE-CHECKPOINT-INHIBITOR-NO-CHEMOTHERAPY

HCPCS M1411: First-Line Immune Checkpoint Inhibitor Without Chemotherapy

HCPCS-M1410-NO-BRCA-GERMLINE-TESTING-OR-GENETIC-COUNSELING-6-MONTHS

HCPCS M1410: No BRCA1/BRCA2 Germline Testing or Genetic Counseling

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

HCPCS Level II M1278: Elevated Blood Pressure with Documented Follow-Up

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who commonly provide routine vaccinations.
`207R00000X`	Internal Medicine	Adult medicine providers administering COVID-19 vaccines during preventive visits.
`3336C0003X`	Pharmacy	Pharmacists certified to provide immunizations in ambulatory and community settings.
`208D00000X`	Pediatrics	Pediatricians administering vaccines to children and adolescents.
`363L00000X`	Public Health	Public health clinicians and immunization program staff providing mass vaccination services.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z23`	Encounter for immunization	Primary encounter code used when administering preventive vaccines, including COVID-19, to indicate vaccination visit.
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Used when vaccination occurs during a routine preventive exam.
`Z91.020`	Allergy to penicillin (may be substituted with specific vaccine allergy codes as appropriate)	Example of a documented allergy that may be relevant to screening for vaccine contraindications or precautions.
`B97.29`	Other coronavirus as the cause of diseases classified elsewhere	Used for historical context if documenting past COVID-19 infection influencing vaccine timing.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	Example chronic comorbidity that increases risk from COVID-19 and supports vaccination necessity.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90460`	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered	Used when counseling is provided and billing immunization administration for pediatric patients alongside `M1419` documentation of not up to date status.
`90461`	Each additional vaccine/toxoid (when counseling is provided)	Used if multiple vaccines are given at the same visit in addition to the COVID-19 vaccine.
`90471`	Immunization administration (intramuscular, intradermal, subcutaneous) single injection; standalone, first or only component, any age	Commonly billed for single-dose vaccine administration in adults when payer requires CPT billing in addition to HCPCS Level II.
`90472`	Each additional vaccine (same encounter)	Billed when more than one injectable vaccine is administered in the same encounter.
`G0008`	Administration of influenza virus vaccine	May appear alongside as an additional vaccine administration code during seasonal vaccination clinics.
`99070`	Supplies and materials provided by the physician over and above those usually included with the office visit	Used when additional specialized supplies or personal protective equipment are charged in exceptional circumstances.

`22`	Increased procedural services	Use when substantially greater work, time, or technical difficulty is required to counsel and vaccinate (rare for routine vaccination).
`23`	Unusual anesthesia	Use if a vaccination is performed with documented general anesthesia (very uncommon).
`52`	Reduced services	Use when the vaccination service was partially discontinued or not fully performed.
`53`	Discontinued procedure	Use when the vaccination was started but then aborted for patient safety reasons.
`54`	Surgical care only	Generally not applicable; included only if a provider performs only pre/post care in a bundled facility context.
`55`	Postoperative management only	Rarely applicable; use if only post-vaccination management is billed separately.
`56`	Preoperative management only	Rarely applicable; use if only pre-vaccination evaluation is billed separately.
`62`	Two surgeons	Use when two qualified providers are required for administration due to unusual circumstances.
`AS`	Non‑participating physician/surgical assistant	Use when an assistant-at-surgery is non-participating and involved in the encounter (rare).
`CO`	Spell of illness unrelated to current episode	Use to indicate unrelated care contexts when payor requires this modifier (context-specific).
`CQ`	Service furnished by a state or local public health agency	Use when the vaccine is administered directly by a public health agency.
`FX`	Stronger procedural component	Use when documenting that the procedural component predominates in a split/bundled service context.
`FY`	Professional component	Use when billing only the professional component of a bundled service (rare for vaccines).
`QK`	Medical direction of two, three, or four technicians/assistants	Use when the physician medically directs multiple personnel involved in vaccination activities.
`QX`	CRNA service with medical direction by physician	Use if a CRNA documents involvement in medication administration or monitoring during procedural sedation for vaccination (rare).

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