Blue Cross Blue Shield RI Vaccine Coding Coverage

Coverage Criteria

Medicare Advantage coverage criteria (partial)

Medicare Advantage coverage and claim coding requirements (partial):

ALL of the following

Covered vaccine/toxoid codes (Part B)
- 90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, intramuscular
- 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, intramuscular
- 90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, subcutaneous (age 18+).
- 90622 Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, percutaneous (age 12 months+).
- 90626 Tick-borne encephalitis virus vaccine, inactivated, 0.25 mL dosage, intramuscular.
Diagnosis requirement for Rabies: Z20.3 must be placed in the first position on the claim for correct claims processing.
Place Z20.3 in first position on claim
Diagnosis requirement for Hepatitis B (individuals at high or intermediate risk): include ICD-10-CM code Z23 (Encounter for immunization) with the applicable CPT vaccine codes.

Claims for Medicare Advantage Plans follow Part B coverage as listed above.

Commercial coverage criteria (partial)

Commercial product coverage (partial):

ALL of the following

Covered commercial vaccine/toxoid codes (selected examples)
- 90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL, IM.
- 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL, IM.
- 90382 Respiratory syncytotic virus, monoclonal antibody, seasonal dose; 0.7 mL, IM.
- 90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL, subcutaneous (age 18+).

Coverage, exclusions and billing rules

Coverage and exclusions called out in this portion:

ALL of the following

Coverage statement: Numerous CPT/HCPCS vaccine/toxoid codes enumerated in the Commercial section are covered for Commercial products (see code lists).
See enumerated codes in Commercial Products sections
Exclusion: Specific CPT immunization codes (for example 90666, 90667 — pandemic influenza formulations) are non-covered/contract exclusions as applicable for Medicare.
Coverage statement: Certain travel vaccine CPT codes (90625 cholera; 90690/90691 typhoid; 90717 yellow fever; 90738 Japanese encephalitis; 90589 chikungunya) are covered for Commercial products.
Exclusion: CPT preventive counseling codes 99401–99404 and 99411–99412 are non-covered when used for travel immunization counseling.

Coding — Vaccine and Administration Codes

Administration and selected vaccine codes (partial list)CPTCovered

90460	Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified health care professional (applies to NP, PA with NPI): first vaccine/toxoid component.
90461	Immunization administration through 18 years of age via any route of administration, with counseling by a physician or other qualified health care professional (applies to NP, PA with NPI): each additional vaccine/toxoid component.
90471	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid).
90472	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid).
90473	Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid).
90474	Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid).
90480	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose.
90612	Influenza virus vaccine, trivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 31.7 mcg/0.32 mL dosage, for intramuscular use.
90613	Influenza virus vaccine, quadrivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 40 mcg/0.4 mL dosage, for intramuscular use.
96380	Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional.

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Medicare Advantage vaccine/toxoid codes (partial list)CPT | HCPCSCovered

90380	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
90381	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use
90611	Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use; for use in patients aged 18 years and older
90622	Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use; for patients aged 12 months and older
90626	Tick-borne encephalitis virus vaccine, inactivated: 0.25 mL dosage, for intramuscular use
90627	Tick-borne encephalitis virus vaccine, inactivated: 0.5 mL dosage, for intramuscular use (effective 7/1/2022; deleted by CPT effective 1/1/2025)
90635	Influenza virus vaccine, H5N1, derived from cell cultures, adjuvanted, for intramuscular use
90637	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, for intramuscular use
90638	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, for intramuscular use
90653	Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use (deleted by CPT effective 1/1/2025)

Commercial product vaccine/toxoid codes (partial list)CPT | HCPCSCovered

90380	RSV monoclonal antibody seasonal dose; 0.5 mL dosage, for intramuscular use
90381	RSV monoclonal antibody seasonal dose; 1 mL dosage, for intramuscular use
90382	RSV monoclonal antibody seasonal dose; 0.7 mL dosage, for intramuscular use
90678	Respiratory syncytial virus (RSV) vaccine, preF, subunit, bivalent, for intramuscular use (Effective 10/1/2023)
90679	Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Effective 10/1/2023)
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use
90750	Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection (age 50 years of age and above includes the 2 dose vaccine)
91318	SARS-CoV-2 vaccine, mRNA-LNP, spike protein, 3 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
91319	SARS-CoV-2 vaccine, mRNA-LNP, spike protein, 10 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
91320	SARS-CoV-2 vaccine, mRNA-LNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use

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Enumerated vaccine CPT/HCPCS codes and statusmixed

90733	Meningococcal polysaccharide vaccine (MPSV4), for subcutaneous use
90734	Meningococcal conjugate vaccine (MCV4/MenACWY), for intramuscular use
90736	Zoster (shingles) vaccine (HZV), live, for subcutaneous injection (age 50+).
90750	Zoster, recombinant, sub-unit, adjuvanted (age 50+), intramuscular (2-dose)
90739	Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use
90740	Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use
90756	Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, for intramuscular use
90759	Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3 dose schedule, for intramuscular use (effective 7/1/2022)
90758	Zaire ebolavirus vaccine, live, for intramuscular use (Effective 7/1/2021)
91318	SARS-CoV-2 mRNA-LNP vaccine, 3 mcg/0.2 mL (commercial listing)

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Administration add-on usage

Add-on codesUse administration add-on codes 90461, 90472, or 90474 when multiple vaccines are administered on the same date by the same provider; indicate the number of units used.

Same-date, same-provider ruleApplies when multiple vaccines are given on the same date of service by the same provider (file with add-on codes rather than separate primary administration codes).

Unit reportingWhen filing add-on codes, report the number of units corresponding to additional vaccine/toxoid components administered on that date.

Applicable settingInstruction appears in the CODING section and applies to claims filing for both Medicare Advantage and Commercial products as stated elsewhere in the policy.

Provider Actions and Billing Guidance

Billing Rule

File multiple same-day vaccine administrations with add-on codes

When multiple vaccines are administered on the same date of service by the same provider, file claims using the administration add-on codes and indicate the number of units used.

Use add-on CPT codes 90461, 90472, or 90474 for additional vaccine/toxoid components.
Report the number of units to reflect multiple vaccines given the same date by the same provider.

Billing Rule

HCPCS vaccine administration codes reimbursed separately for Medicare Advantage

For Medicare Advantage Plans, the HCPCS administration codes G0008, G0009, and G0010 are separately reimbursed.

G0008 — Administration of influenza virus vaccine (separately reimbursed).
G0009 — Administration of pneumococcal vaccine (separately reimbursed).

Definitions, Scope, and Exclusions

Contact with and (suspected) exposure to rabies

ICD‑10 codeZ20.3

DescriptionContact with and (suspected) exposure to rabies.

Claim positioningPlace Z20.3 in the first (primary) diagnosis position on the claim form for rabies-related vaccine or treatment claims.

ApplicabilityRequired for Medicare Part B coverage (and Commercial where noted) when filing with applicable CPT vaccine codes for rabies in individuals at high or intermediate risk.

Encounter for immunization (Hepatitis B claims)

ICD‑10 codeZ23

Description

OpenPayer

Vaccine and Immunization Coding and Coverage (Medicare Advantage and Commercial)

Coverage Criteria

Coding — Vaccine and Administration Codes

Provider Actions and Billing Guidance

Definitions, Scope, and Exclusions