CurrentCareFirstPolicy N/A

Respiratory Syncytial Virus (RSV) Vaccination And Administration Billing Guidelines

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Guidance for billing and coding of Respiratory Syncytial Virus (RSV) vaccines and their administration for CareFirst providers, including applicable CPT and ICD-10 codes and payer stance on prior authorization for specific products.

Policy Summary

PayerCareFirst

PolicyRespiratory Syncytial Virus (RSV) Vaccination And Administration Billing Guidelines

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage change)

Effective DateOct 6, 2023

Next Review DateN/A

Key ActionAllow 30 days from the code effective date before billing new CPT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 96380/96381administration codes effective 10/06/2023

BeyfortusBeyfortus — no PA

Age 60+Abrysvo — ACIP approved

ArexvyArexvy — no PA

Z29.11 / Z23Reporting diagnosis codes

Product-specific Coverage Criteria

Product-specific coverage criteria

Coverage is conditional based on product, patient age, season, and pregnancy trimester. The following criteria must be met for coverage.

Beyfortus (nirsevimab-alip) — inpatient newborn administration may be reported using ICD-10 Z29.11; ACIP approved 08/03/2023; no prior authorization required (see age-based dose rules below).

Beyfortus age and season criteria

First season, 1st dose: for ages up to 8 months — CPT codes 90380 and 90381.
First season, 1st dose: for ages older than 8 months through 19 months — CPT codes 90380 and 90381 (may not qualify for second season dose if > 19 months).
Second season, 2nd dose: for ages 8 months through 19 months who are at increased risk for severe disease — CPT codes 90380 and 90381.

Abrysvo — ACIP approved 08/21/2023 for adults age 60+ and may be administered in pregnancy third trimester with specified ICD-10 pregnancy diagnosis codes; CPT code 90678. If billed under age 60 without an allowed maternity diagnosis, the claim will deny as experimental/investigational.

Pregnancy third trimester diagnosis codes required for Abrysvo pregnancy dosing (examples include Z34.03, Z34.83, Z34.93, O09.03, O09.13, O09.A3, O09.213, O09.293, O09.33, O09.43, O09.513, O09.523, O09.613, O09.623, O09.73, O09.813, O09.823).

Arexvy — ACIP approved 06/21/2023 for adults age 60+; no prior authorization required — CPT code 90679; report using ICD-10 Z23 for age-60+ immunization encounters.

Vaccine and Administration Coding

Covered CPT/HCPCS/ICD Codes for RSV vaccines and administrationmixedCovered

96380	Therapeutic, prophylactic, or diagnostic injection; initial
96381	Therapeutic, prophylactic, or diagnostic injection; subsequent
90380	RSV vaccine product code referenced for first season dosing (Beyfortus first season 1st dose)
90381	RSV vaccine product code referenced for first and second season dosing (Beyfortus)
90678	Vaccine code referenced for Abrysvo (adults 60+ and/or pregnancy 3rd trimester)
90679	Vaccine code referenced for Arexvy (adults 60+)
Z29.11	Encounter for immunization for newborns (used to report inpatient Beyfortus administration)
Z23	Encounter for immunization (used to report age 60+ RSV vaccine administration)

Age-based coverage thresholds

Beyfortus (nirsevimab-alip)First season: 1st dose for infants up to 8 months; second‑season 2nd dose for select infants aged 8 through 19 months at increased risk

Beyfortus CPT codes90380, 90381 for first‑ and second‑season dosing

Newborn inpatient reportingInpatient administration of Beyfortus should be reported with ICD‑10 Z29.11

Billing Actions & Authorization Notes

Prior Authorization

Prior authorization and denial risks for RSV products

No prior authorization is required for Beyfortus (nirsevimab-alip) and Arexvy per ACIP approval notes; billing Abrysvo for persons under age 60 without a listed maternity diagnosis may be denied as experimental and investigational.

Beyfortus (ACIP approved 08/03/2023): no prior authorization required; inpatient newborn administration should be reported with ICD-10 Z29.11.
Arexvy (ACIP approved 06/21/2023): no prior authorization required for adults age 60+.
Abrysvo (ACIP approved 08/21/2023): if billed for patients under age 60 without a listed maternity diagnosis, the claim will deny as experimental and investigational.

Billing Rule

Billing timing advisory for new CPT codes

Wait at least 30 days from the CPT code effective date before submitting claims for the new administration codes to avoid premature billing.

New CPT administration codes 96380 and 96381 are effective 10/6/2023; allow 30 days from the code effective date before billing.

Product Definitions & Notes

Beyfortus (nirsevimab‑alip)

ProductBeyfortus (nirsevimab‑alip)

IndicationMonoclonal antibody RSV prophylaxis for infants (first season and selected second‑season dosing)

ACIP approval date08/03/2023

Prior authorizationNo prior authorization required per ACIP approval

Reporting codeICD‑10 Z29.11 for inpatient newborn administration

Abrysvo

ProductAbrysvo

IndicationsAdults age 60+; administration in third trimester pregnancy with specified pregnancy ICD‑10 codes

ACIP approval date (age 60+)08/21/2023

Pregnancy ICD‑10 guidanceThird‑trimester pregnancy dosing supported; claims billed for patients <60 without a listed maternity diagnosis may deny as experimental/investigational

CPT code90678

Arexvy

ProductArexvy

IndicationRSV vaccine for adults age 60+

ACIP approval date06/21/2023

Prior authorizationNo prior authorization required

CPT code90679

Policy Summary

PayerCareFirst

PolicyRespiratory Syncytial Virus (RSV) Vaccination And Administration Billing Guidelines

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage change)

Effective DateOct 6, 2023

Next Review DateN/A

Key ActionAllow 30 days from the code effective date before billing new CPT codes.

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Respiratory Syncytial Virus (RSV) Vaccination And Administration Billing Guidelines

Customize your policy alerts

Sign up for all CareFirst policy alerts

Know when CareFirst releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Product-specific Coverage Criteria

Product-specific coverage criteria

Coverage is conditional based on product, patient age, season, and pregnancy trimester. The following criteria must be met for coverage.

Beyfortus (nirsevimab-alip) — inpatient newborn administration may be reported using ICD-10 Z29.11; ACIP approved 08/03/2023; no prior authorization required (see age-based dose rules below).

Beyfortus age and season criteria

First season, 1st dose: for ages up to 8 months — CPT codes 90380 and 90381.
First season, 1st dose: for ages older than 8 months through 19 months — CPT codes 90380 and 90381 (may not qualify for second season dose if > 19 months).
Second season, 2nd dose: for ages 8 months through 19 months who are at increased risk for severe disease — CPT codes 90380 and 90381.

Arexvy — ACIP approved 06/21/2023 for adults age 60+; no prior authorization required — CPT code 90679; report using ICD-10 Z23 for age-60+ immunization encounters.

Vaccine and Administration Coding

Covered CPT/HCPCS/ICD Codes for RSV vaccines and administrationmixedCovered

96380	Therapeutic, prophylactic, or diagnostic injection; initial
96381	Therapeutic, prophylactic, or diagnostic injection; subsequent
90380	RSV vaccine product code referenced for first season dosing (Beyfortus first season 1st dose)
90381	RSV vaccine product code referenced for first and second season dosing (Beyfortus)
90678	Vaccine code referenced for Abrysvo (adults 60+ and/or pregnancy 3rd trimester)
90679	Vaccine code referenced for Arexvy (adults 60+)
Z29.11	Encounter for immunization for newborns (used to report inpatient Beyfortus administration)
Z23	Encounter for immunization (used to report age 60+ RSV vaccine administration)

Age-based coverage thresholds

Beyfortus (nirsevimab-alip)First season: 1st dose for infants up to 8 months; second‑season 2nd dose for select infants aged 8 through 19 months at increased risk

Beyfortus CPT codes90380, 90381 for first‑ and second‑season dosing

Newborn inpatient reportingInpatient administration of Beyfortus should be reported with ICD‑10 Z29.11

Billing Actions & Authorization Notes

Prior Authorization

Prior authorization and denial risks for RSV products

Beyfortus (ACIP approved 08/03/2023): no prior authorization required; inpatient newborn administration should be reported with ICD-10 Z29.11.
Arexvy (ACIP approved 06/21/2023): no prior authorization required for adults age 60+.
Abrysvo (ACIP approved 08/21/2023): if billed for patients under age 60 without a listed maternity diagnosis, the claim will deny as experimental and investigational.

Billing Rule

Billing timing advisory for new CPT codes

Wait at least 30 days from the CPT code effective date before submitting claims for the new administration codes to avoid premature billing.

New CPT administration codes 96380 and 96381 are effective 10/6/2023; allow 30 days from the code effective date before billing.

Product Definitions & Notes

Beyfortus (nirsevimab‑alip)

ProductBeyfortus (nirsevimab‑alip)

IndicationMonoclonal antibody RSV prophylaxis for infants (first season and selected second‑season dosing)

ACIP approval date08/03/2023

Prior authorizationNo prior authorization required per ACIP approval

Reporting codeICD‑10 Z29.11 for inpatient newborn administration

Abrysvo

ProductAbrysvo

IndicationsAdults age 60+; administration in third trimester pregnancy with specified pregnancy ICD‑10 codes

ACIP approval date (age 60+)08/21/2023

Pregnancy ICD‑10 guidanceThird‑trimester pregnancy dosing supported; claims billed for patients <60 without a listed maternity diagnosis may deny as experimental/investigational

CPT code90678

Arexvy

ProductArexvy

IndicationRSV vaccine for adults age 60+

ACIP approval date06/21/2023

Prior authorizationNo prior authorization required

CPT code90679