Summary & Overview
HCPCS S0195: Pneumococcal Conjugate Vaccine for Children 5–9
HCPCS Level II code S0195 denotes a polyvalent pneumococcal conjugate vaccine given intramuscularly to children aged five through nine years who have not previously received the vaccine. This code identifies a targeted pediatric immunization intended to extend protection against multiple pneumococcal serotypes and is used in outpatient and office-based vaccination settings. Nationally, accurate coding for pediatric vaccines is important for public health reporting, immunization program management, and appropriate payer reimbursement.
Key payers covered in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for S0195, expected sites of service, and which payers commonly recognize the code. The publication also outlines benchmarking and policy-relevant considerations for vaccine administration coding, highlights gaps where supplemental data are unavailable, and provides practical references to related billing categories. Content is oriented to billing managers, practice administrators, and policy analysts seeking a national perspective on using HCPCS Level II code S0195 for pediatric pneumococcal immunization.
Billing Code Overview
HCPCS Level II code S0195 describes a pneumococcal conjugate vaccine, polyvalent, administered intramuscularly for children aged five through nine years who have not previously received the vaccine. The service is vaccination with a polyvalent pneumococcal conjugate formulation intended to provide immunization against multiple pneumococcal serotypes in this pediatric age group.
Service Type: Vaccine administration / Immunization
Typical Site of Service: Outpatient clinic, pediatric clinic, public health clinic, or physician office
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Clinical & Coding Specifications
Clinical Context
A 7-year-old child presents to a primary care pediatric clinic for catch-up immunization after relocating with their family. The child has no documented prior pneumococcal conjugate vaccine series. The clinical workflow includes nurse intake with verification of immunization history, review of contraindications (severe allergic reaction to a previous dose or vaccine component), obtaining parental consent, administration of the intramuscular pneumococcal conjugate vaccine appropriate for ages 5–9, documentation in the electronic medical record and immunization registry, billing using S0195, and observation for 15 minutes for immediate adverse reactions. Vaccine lot number, manufacturer, administration site, and VIS (Vaccine Information Statement) date are recorded. Billing and coding staff submit claims to commercial payors such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, or Medicare as applicable, using relevant encounter details and any applicable modifiers for billing nuances.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service | Use when a documented E/M visit is performed on the same day as vaccine administration and meets E/M criteria |