CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Vaccination CPT/HCPCS coverage lists for Medicare Advantage and Commercial products

Lists covered and non-covered vaccine CPT/HCPCS codes and billing notes for Blue Cross Blue Shield - Rhode Island Medicare Advantage Plans and Commercial products; includes diagnosis coding guidance for rabies and hepatitis B claims and references to related policies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyVaccination CPT/HCPCS coverage lists for Medicare Advantage and Commercial products

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 15, 2007

Next Review DateN/A

Key ActionVerify member eligibility and benefits before billing and contact the provider call center for member-specific coverage or payment guarantee information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈150+vaccine CPT/HCPCS codes listed

2diagnosis codes required (Rabies/Hep B)

3related internal policies

16+references cited

Vaccine Coverage and Billing Rules

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Vaccine coverage and billing rules

Coverage and billing rules summarized from the Medicare Advantage and Commercial product sections:

Numerous CPT/HCPCS vaccine and toxoid codes are listed as covered across Medicare Advantage Plans (Part B) and Commercial products; specific codes and effective dates are provided in the policy sections (see Medicare and Commercial lists).

Effective date notes

Certain codes include effective dates (examples from the lists: 90626/90627 effective 7/1/2022; 90759 effective 7/1/2022; 90679 effective 10/1/2023).

Specific pandemic influenza CPT codes are non-covered/contract exclusions for Medicare (examples cited: 90667, 90668 and pandemic formulation split virus).

Travel vaccine CPT codes are covered for Commercial products (examples in the Commercial list include 90625 cholera; 90690/90691 typhoid; 90717 yellow fever; 90738 Japanese encephalitis).

Individual and group preventive counseling CPT codes (travel-related immunization counseling) are non-covered when used for travel (examples: 99402, 99403, 99404, 99411, 99412).

For rabies and hepatitis B vaccines administered to individuals at high or intermediate risk (Medicare Part B and Commercial), include the required ICD-10-CM diagnosis codes on the claim: Rabies exposure Z20.3 (must be placed in the first position on the claim) and for hepatitis B include the encounter for immunization code Z23 as applicable.

Administration HCPCS codes (influenza, pneumococcal, hepatitis B administration) are separately reimbursed for Medicare Advantage Plans; providers should refer to the Preventive Services policy for correct coding and reimbursement rules.

Unlisted/unspecified vaccine coding

When billing for unlisted vaccine/toxoid or unspecified influenza vaccine codes, follow the unlisted procedures process (examples: Q2039, 90749).

Providers should verify member-specific eligibility and benefits prior to billing; the policy is informational and not a guarantee of payment.

Codes, Diagnosis Requirements, and Coding Notes

Selected notable covered vaccine codesCPTCovered

90627	Tick-borne encephalitis virus vaccine; inactivated; 0.5 mL IM (effective 7/1/2022)
90626	Tick-borne encephalitis vaccine; inactivated; 0.25 mL IM (effective 7/1/2022)
90759	Hepatitis B vaccine, 3-antigen, 10 mcg; 3 dose schedule (effective 7/1/2022)
90679	Respiratory syncytial virus vaccine; recombinant; subunit; adjuvanted (Effective 10/1/2023)
91318	SARS-CoV-2 vaccine, mRNA-LNP, 3 mcg/0.3 mL
Q2034	Influenza vaccine, split virus (Agriflu)
90749	Unlisted vaccine/toxoid

Referenced vaccine codeCPT

90636

CPT/HCPCS code referenced in document (article reference)

inv-04: Diagnosis requirement for certain vaccines

Required diagnosis codesFor Medicare Part B and Commercial claims when Rabies or Hepatitis B vaccines are administered to individuals at high or intermediate risk, include the specified ICD-10-CM diagnosis codes on the claim.

Rabies codeZ20.3 — Contact with and (suspected) exposure to rabies; must be placed in the first (primary) position on the claim form for correct claims processing.

Hepatitis B codeZ23 — Encounter for immunization; include with applicable CPT vaccine codes for Hepatitis B vaccinations.

Billing Notes and Provider Responsibilities

Prior Authorization

Unlisted vaccine/toxoid and unspecified influenza vaccine

For the listed codes Q2039 and 90749, follow the unlisted procedures process as directed in the policy when billing these vaccine/toxoid items.

Billing Rule

Vaccine administration reimbursement note

Administration HCPCS codes (e.g., for influenza, pneumococcal, hepatitis B) are separately reimbursed for Medicare Advantage Plans; providers must refer to the separate Preventive Services for Medicare Advantage Plans policy for correct coding and reimbursement.

Documentation Required

Provider action and contact

Verify member-specific benefits and eligibility with the provider call center before billing; obtain written agreement from the member before charging for services determined to be non-covered or not medically necessary.

Benefits and eligibility are defined by the member's subscriber agreement or employer agreement and supersede this policy.
Do not charge members for non-covered services unless the member has been informed and has agreed in writing in advance.

Diagnosis Codes and Policy Disclaimer

inv-08: Contact with and (suspected) exposure to rabies — required diagnosis for claim processing of rabies vaccine; must be first-listed on claim form

Required primary diagnosis for rabies vaccine claimsZ20.3 — Contact with and (suspected) exposure to rabies; must be first-listed on the claim form for correct claims processing.

Use caseApply when processing claims for rabies vaccine provided to individuals with suspected exposure or contact; ensures Medicare Part B and Commercial adjudication aligns with policy requirements.

Documentation noteInclude supporting clinical documentation of exposure/contact to justify placement of Z20.3 as the primary diagnosis if requested during review.

inv-09: Encounter for immunization — diagnosis code required with applicable CPT vaccine codes for Hepatitis B

Required diagnosis for Hepatitis B vaccination claimsZ23 — Encounter for immunization; must be reported with applicable CPT vaccine codes for Hepatitis B when administering to individuals under the referenced benefit rules.

ScopeApplies to Medicare Part B and Commercial product claim submissions where Hepatitis B vaccine is furnished under the documented coverage rules.

Claim pairingReport Z23 in the claim diagnosis fields in conjunction with the Hepatitis B CPT/HCPCS code(s) to support preventive immunization processing.

inv-10: Policy disclaimer

Informational purpose onlyThis medical policy is made available for informational purposes only and is not a guarantee of payment or a substitute for clinical judgment.

Benefits and eligibilityBenefits and eligibility are determined by the member’s subscriber agreement, member certificate, and/or the employer agreement; those documents supersede this policy.

Provider billing and member chargesFor services determined to be not medically necessary or non-covered, providers may not charge the member unless the member was informed and agreed in writing in advance to pay out-of-pocket.

Policy maintenanceBCBSRI reserves the right to review and revise this policy at any time, with or without notice; the policy is current at time of publication.