Modifiedharvard pilgrim health carePolicy N/A

Preventive Care Services coverage

Defines preventive services covered without cost-sharing for in-network members, lists covered preventive screenings, counseling, supplies and associated coding guidance; applies to Tufts Health Plan commercial members and in-network providers.

Policy Summary

Payerharvard pilgrim health care

PolicyPreventive Care Services coverage

Policy CodePolicy N/A

Change TypeMaterial updates to immunization and screening codesage criteria revised

Effective DateN/A

Next Review DateN/A

Key ActionBill preventive services with a preventive/screening diagnosis code in the primary position to receive preventive benefit.

SourceLink

POLICY UPDATE CHANGES

Added codes 90382, 90612, 90613, 90631, 90635, 91323 under Immunizations.

Removed code 90631 under Immunizations.

Updated age criteria for multiple immunization codes (90380, 90381, 90644, 90678, 90679, 90683, 90734 and later for 90670, 90671, 90677, 90684, 90732).

Added codes 90481, 90482, 90483, 90484 under Immunizations.

Added multiple breast cancer screening procedure and diagnosis codes and expanded pathology codes; updated Osteoporosis Screening age from 50 to 40.

~100+listed preventive procedure and HCPCS/CPT/ICD codes (document excerpt)

50-80lung LDCT screening age range

45-75Cologuard coverage age range

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

50→40Osteoporosis Screening age lowered

multipleimmunization codes changed in history

90630, 90654examples of removed codes

Coverage Criteria — Preventive Services

General Preventive Benefit Criteria

Preventive services are covered without cost-sharing when rendered by an in-network provider and billed with appropriate preventive diagnosis codes in the primary position.

General preventive coverage: Service is performed by an in-network provider AND billed with a preventive/screening/wellness diagnosis code in the primary position

Out-of-network preventive services may have cost-sharing per plan; diagnostic services billed as non-preventive will be adjudicated under non-preventive benefits

Abdominal Aortic Aneurysm Screening

AAA screening covered when ALL of the following are met:

AAA screening criteria: Patient is a man age 65-75 (screening ends on 76th birthday) AND has prior history of smoking AND screening billed with one of the listed ICD-10 codes (e.g., F17.*, Z00.00, Z13.6, Z87.891)Once per lifetime

Covered when billed with one of the listed ICD-10 codes

Lung Cancer Screening (Low-Dose CT)

Lung cancer LDCT screening covered when ALL of the following are met:

LDCT criteria: Patient age 50-80 years AND 20 pack-year smoking history AND currently smokes or quit within the past 15 years AND screening billed with one of the listed ICD-10 codes (examples include F17.* and relevant Z codes)

Procedure code 71271 (LDCT) requires prior authorization

Colorectal Cancer Screening

Colorectal cancer screening (including colonoscopy and stool DNA) covered when billed with listed ICD-10 codes and meeting age/frequency criteria:

Colorectal modalities: Screening colonoscopy billed with screening colonoscopy codes (use 00812 for screening; 00811 if screening converts to diagnostic) OR stool DNA testing (Cologuard 81528 or 0464U) for ages 45-75 once every 3 yearsCologuard: once every 3 years; ages 45-75

Prep kits/items require prescription coverage; inpatient and emergency room colonoscopies are excluded from the preventive benefit and diagnosis must be in the primary position

Breastfeeding Interventions and Equipment

Breastfeeding support and equipment covered with limits:

Breastfeeding equipment: Lactation services (S9443/99502) covered when billed with listed diagnosis codes AND breast pumps E0602 (manual) or E0603 (electric) subject to purchase frequency limits AND hospital-grade pump rental E0604 limited to a 3-month rental then returnE0604 rental: 3 months

Some supply HCPCS (A4281–A4288) have purchase frequency limits; 99502 limited to one visit every 8 rolling months

HIV Screening and PrEP

HIV-related preventive services covered as preventive when billed with listed ICD-10 codes:

HIV screening and PrEP components: HIV screening covered for adolescents/adults ages 15-65 (younger/older if increased risk) and all pregnant persons when billed with listed ICD-10 codes (e.g., Z11.4); includes HIV testing, adherence counseling, creatinine/eCrCl or eGFR testing, hepatitis B and C testing, and pregnancy testing as part of PrEP care

Specific procedure and HCPCS codes (testing and PrEP drugs) are listed in the coding section; some PrEP drugs may require prior authorization

General immunization coverage conditions

Covered preventive immunizations

Baseline coverage conditions: An immunization is considered covered when it is FDA approved AND has explicit ACIP recommendations for routine use published in the CDC MMWR; implementation will typically occur within 60 days after MMWR publication

Immunizations excluded by the member's Certificate of Coverage are not considered covered even if FDA approved/ACIP-recommended; immunization encounters should be billed with Z23 when specified

Newborn screenings

Newborn screening coverage

Newborn screenings: Hearing screening, hypothyroidism screening, phenylketonuria screening, and sickle cell screening are covered when billed with one of the listed ICD-10 codes and within specified age ranges: phenylketonuria 0–60 days; hypothyroidism 0–180 days; sickle cell 0–180 days; hearing screening covered through age 21 when billed with listed ICD-10 codesage-based

See newborn screening procedure and ICD-10 code listings in the coding section

Screenings: Obesity and Osteoporosis

Obesity and osteoporosis screening coverage

Obesity screening and counseling for adults, children, and adolescents is covered when billed with the listed CPT/HCPCS and ICD-10 codes; if billed with an E&M service, modifier 25 must be appended

Preventive services may require Modifier 33 as noted elsewhere

Osteoporosis screening: Bone density (DEXA) screening is covered when billed with the listed CPT/HCPCS and ICD-10 codes for all persons age 40 and olderage >= 40

See coding section for specific procedure codes (e.g., 77080) and HCPCS

Immunization administration and counseling

Immunization administration and counseling coverage

Administration coding: Immunization administration codes (90460–90474; 90480–90484) and immunization counseling codes (90482–90483) are covered as preventive services when billed with appropriate diagnosis codes; certain counseling and administration codes must be billed with Z23 or Z71.85 in the primary position when specified

Providers must report appropriate administration codes (examples G0008, G0009, G0010) as applicable

HPV vaccine coverage and age limits

HPV coverage limits: Gardasil4 (HPV4) reimbursed for ages 9–26; Gardasil9 (9vHPV) coverage is limited to ages 9–45. When a three-dose series is begun by age 26, subsequent injections may be covered into age 27 to complete the seriesage-based

No coverage beyond stated age limits for HPV vaccines (Gardasil9 limited to ages 9–45)

Product-specific coverage notes

Product-specific coverage notes and situational recommendations

Age-based or risk-based coverage notes: Certain vaccines include age- or risk-based coverage guidance (examples: PCV15 series schedule at 2, 4, 6 and 12–15 months; PCV13/PCV15/PCV20/PCV21 recommendations for adults with specific risk conditions and older adults; Shingrix coverage limited to age 18 and over; RSV vaccine indications vary by pediatric, adult age and pregnancy status)

Refer to product-specific entries and coding table for exact age indications and schedules

Inpatient and emergency room colonoscopies are explicitly excluded from the Preventive Care benefit. For outpatient screening colonoscopy billing, use the screening colonoscopy code (for example 00812) and ensure the preventive/screening diagnosis is reported in the primary position. If a screening colonoscopy converts to a diagnostic procedure during the same encounter, bill the appropriate diagnostic colonoscopy code (for example 00811) and note that preventive benefit eligibility will be reconsidered based on the primary diagnosis.

An immunization that is excluded by the member’s Certificate of Coverage is not considered a covered preventive immunization even if the product has FDA approval or an ACIP recommendation. The policy defines a covered immunization as one that has FDA approval and an explicit ACIP recommendation published in the CDC MMWR, with implementation typically occurring within 60 days of MMWR publication.

The recombinant zoster vaccine (Shingrix, CPT/HCPCS entry 90748) is listed with a product-specific coverage limitation: coverage is limited to individuals aged 18 years and over as stated in the product comment.

Publication history entries show that specific procedure codes have been removed from the immunization and preventive code lists over time. Claims submitted with codes that were removed in the publication history (examples documented include codes such as 90630, 90654, 90631, J1810) may no longer be covered and could be denied if submitted after the effective removal date; providers should reference the publication history when selecting codes.

Human papillomavirus vaccine coverage limits are product-specific. For the nonavalent HPV vaccine (Gardasil9 and related listings), coverage is limited by age—specifically the policy restricts coverage to ages 9 through 45 (series begun by age 26 may be completed into age 27 for the three-dose schedule as noted for other HPV products).

Coding — Procedure, Diagnosis and Vaccine Codes

AAA Screening CPTCPTCovered

76706

Abdominal aortic ultrasound (AAA screening) procedure code

Alcohol Misuse ScreeningmixedCovered

99408	Alcohol misuse screening/brief intervention
99409	Alcohol misuse screening/brief intervention
G0442	Alcohol misuse screening HCPCS
G0443	Alcohol misuse screening HCPCS

Breast Cancer Screening / MammographymixedCovered

77067	Screening mammography, bilateral
G0279	HCPCS mammography

Colorectal Cancer Screening CodesmixedCovered

45378	Colonoscopy procedure code (example list includes many CPTs)
81528	Cologuard mt-sDNA assay
0464U	Cologuard Plus (lab-specific code)

Lung Cancer ScreeningmixedCovered

71271	Low-dose CT chest for lung cancer screening
G0296	LDCT lung cancer screening HCPCS

Hepatitis B and C ScreeningmixedCovered

G0472	Hepatitis C screening HCPCS
86803	Hepatitis C antibody

Contraception - Devices and AppsHCPCSCovered

A9293	Fertility cycle tracking software application (Natural Cycles)
J7300	Intrauterine device HCPCS example

Breastfeeding EquipmentHCPCSCovered

E0602	Manual breast pump purchase code
E0603	Electric breast pump purchase code
E0604	Hospital grade breast pump rental code

Depression and Suicide Risk ScreeningmixedCovered

G0444	Annual depression screening HCPCS
99384	Preventive medicine, new patient (example E/M included)

Osteoporosis ScreeningmixedCovered

77080	Bone density (DEXA) procedure code
G0130	Bone mass measurement HCPCS

Newborn screening procedure codesCPTCovered

84030	Phenylketonuria screening
84510	Phenylketonuria screening (alternate)
83020	Sickle cell screening
83021	Sickle cell screening
83030	Sickle cell screening
83033	Sickle cell screening
83051	Sickle cell screening
85660	Sickle cell screening

Obesity screening/counseling codesmixedCovered

97802	Obesity screening/counseling
97803	Obesity screening/counseling
97804	Obesity screening/counseling
99401	Preventive counseling
99402	Preventive counseling
99403	Preventive counseling
99404	Preventive counseling
G0473	Obesity counseling HCPC
S9470	Obesity counseling HCPC

Preventive medical exam codesmixedCovered

99381	Preventive medical exam
99382	Preventive medical exam
99383	Preventive medical exam
99384	Preventive medical exam
99385	Preventive medical exam
99386	Preventive medical exam
99387	Preventive medical exam
99391	Preventive medical exam (established)
99392	Preventive medical exam (established)
99393	Preventive medical exam (established)

1–10 of 16

1/2

Immunization administration and vaccine CPT codes (selected list)CPTCovered

90460	Immunization administration through 18 yrs, first or only component
90461	Immunization administration through 18 yrs, additional component
90471	Immunization administration; one vaccine (injection)
90472	Immunization administration; each additional vaccine (injection)
90473	Immunization administration by intranasal or oral route; one vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine
90480	Immunization administration COVID-19 single dose (IM)
90481	Immunization administration COVID-19 additional component
90482	Immunization counseling (3-10 minutes) when immunization not administered
90483	Immunization counseling (>10-20 minutes) when immunization not administered

1–10 of 37

1/4

ICD-10 diagnosis codes used for preventive services/immunizationsICD-10Covered

Z00.110	Newborn preventive visit
Z00.111	Newborn preventive visit
Z00.121	Newborn hearing and vision screening
Z00.129	Newborn preventive visit
Z13.0	Screening for mental and behavioral disorders (listed)
Z13.228	Phenylketonuria screening related
Z23	Encounter for immunization
Z71.85	Immunization counseling

Vaccine and administration codesmixed

90660	Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, IM
90661	Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, IM
90662	Influenza virus vaccine, live (Flumist) LAIV, intranasal
90664	Influenza virus vaccine, live, pandemic formulation, intranasal
90666	Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, IM
90667	Pneumococcal conjugate vaccine, 13 valent (PCV13), IM
90670	Pneumococcal conjugate vaccine, 15 valent (PCV15), IM
90671	Influenza virus vaccine, quadrivalent, live (LAIV4), intranasal
90672	Influenza virus vaccine, trivalent (RIV3), recombinant (Flublok), IM
90673	Influenza virus vaccine, quadrivalent (ccIIV4), cell culture derived, IM

1–10 of 68

1/7

Influenza vaccine Q-codesHCPCSCovered

Q2037	Fluvirin (influenza virus vaccine, split virus) for individuals 3 years of age and older
Q2038	Fluzone (influenza virus vaccine, split virus) for individuals 3 years of age and older
Q2039	Influenza virus vaccine, not otherwise specified

Immunization procedure and administration codes (added/updated/removed across publication history)CPT/HCPCS

90380
90381
90611
90612
90613
90619
90622
90624
90631
90635

1–10 of 27

1/3

Breast cancer screening procedure codes addedCPT | HCPCSCovered

19081
19082
19083
19084
19085
19086
19100
19101
19499
76641

1–10 of 23

1/3

Breast cancer screening diagnosis codes added/updatedICD-10Covered

Z80.44
C50.011
C50.929
C79.81
D05.00
D05.92
D24.1
D24.2
D24.9
D48.60

1–10 of 29

1/3

AAA screening eligibility summary (men 65-75 with smoking history)

Eligible populationMen age 65-75 (screening ends on 76th birthday) with a prior history of smoking

FrequencyOnce per lifetime

Required billingBilled with one of the listed ICD-10 codes (see AAA coding list) in the primary position

Provider Actions — Billing, Documentation and Prior Auth

Prior Authorization

BRCA testing prior authorization

BRCA genetic testing and associated genetic counseling may require prior authorization when billed as preventive services. Verify prior authorization requirements before scheduling or submitting claims.

Affected procedure codes: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217
Related counseling code: 96041 (updated from 96040)

Note

Voluntary sterilization — see contraception section

Voluntary sterilization coding and authorization details are maintained under the contraception methods section. Reference the Contraception Methods section for the correct CPT/HCPCS codes and any prior authorization or coverage limits.

Do not bill using standalone sterilization rules listed elsewhere; follow contraception section coding and authorization guidance.

Background and Scope

This policy lists preventive screenings and interventions recommended by authoritative bodies (for example USPSTF, Bright Futures, AAP, CDC/ACIP and HRSA) and specifies when those services are payable as Preventive Care Services without member cost‑sharing. It clarifies coding expectations required to qualify for preventive benefits (for example, preventive/screening/wellness diagnosis codes must be billed in the primary position) and includes age- and risk-based eligibility and frequency limits for specific screenings and immunizations.

Definitions and Key Terms

Preventive Care Services definition — in-network services identified by USPSTF, Bright Futures, AAP, CDC, HRSA guidance

DefinitionPreventive Care Services are services rendered by an in-network provider identified as preventive under USPSTF, Bright Futures, AAP, CDC, and HRSA guidance and adjudicated as preventive when billed with appropriate preventive diagnosis codes in the primary position

Implementation noteImmunizations are considered covered when FDA-approved and explicitly ACIP-recommended in the CDC MMWR; implementation typically within 60 days of MMWR publication

Billing requirementPreventive services must be billed with a preventive/screening/wellness diagnosis code in the primary position to qualify for no cost-sharing

Modifier 33 definition and usage note

What it isModifier 33 is a code that may be reported for certain preventive services to indicate preventive intent

Publication History and Material Changes

01/01/25policy_creation

New Preventive Care Services policy created; multiple code additions and edits including addition of 90593 and 90619 to Immunizations and other coding updates.

03/01/25code_update

Added immunization code 90624 and removed immunization codes 90630 and 90654; added age criteria for multiple immunization codes (90380, 90381, 90644, 90678, 90679, 90683, 90734).

04/01/25code_update

Policy Summary

Payerharvard pilgrim health care

PolicyPreventive Care Services coverage

Policy CodePolicy N/A

Change TypeMaterial updates to immunization and screening codesage criteria revised

Effective DateN/A

Next Review DateN/A

Key ActionBill preventive services with a preventive/screening diagnosis code in the primary position to receive preventive benefit.

SourceLink

On This Page

Procedure codeCPT 76706 (abdominal aortic ultrasound)

Lung cancer LDCT eligibility summary (ages 50-80, 20 pack-year, current or quit ≤15 yrs)

Age rangeAdults 50-80 years

Smoking historyMinimum 20 pack-year history

Current or former smokersCurrently smoke or quit within the past 15 years

Procedure and PACPT 71271 (LDCT); 71271 requires prior authorization; HCPCS G0296 listed

Cologuard frequency and age (ages 45-75, once every 3 years)

Covered agesAges 45-75

FrequencyOnce every 3 years for Cologuard (81528) / Cologuard Plus (0464U)

Billing notesUse screening colonoscopy codes (00812) for screening; inpatient/ER colonoscopies excluded from preventive benefit

Newborn screening age thresholds (PKU, hearing, hypothyroidism, sickle cell guidance)

Phenylketonuria (PKU)Covered for newborns ages 0-60 days when billed with listed ICD-10 codes

Hearing screeningCovered through age 21 when billed with one of the listed ICD-10 codes (newborn hearing codes listed)

HypothyroidismCovered for newborns ages 0-180 days when billed with listed ICD-10 codes

Sickle cellCovered for newborns ages 0-180 days when billed with one of the listed ICD-10 codes

HPV coverage age limit (Gardasil9 ages 9-45)

Vaccine and age limitGardasil9 (nonavalent) coverage limited to ages 9-45

Series completion noteWhen the 3-dose series is begun by age 26, subsequent injections may be covered into age 27 to complete the series (applies to HPV4 example)

Relevant codesCPT references include 90649 (Gardasil4) and Gardasil9 series references noted in immunization lists

Age or schedule notes for select vaccines (PCV15/PCV13, Shingrix limitations, etc.)

PCV15 schedulePCV15 series recommended at 2, 4, 6 and 12-15 months (product comment)

PCV13 adult recommendationPCV13 (Prevnar 13) recommended for adults ≥19 with certain conditions (product comment)

Shingrix limitationShingrix (90748) coverage limited to age 18 years and over (product comment)

RSV and other age notesRSV vaccine indications include young children 8-19 months and older adult age groups per product comments

Influenza vaccine minimum age (>= 3 years)

Minimum age for intramuscular influenza productsIndividuals 3 years of age and older (e.g., Fluzone, Fluvirin)

Q-code examplesQ2037 (Fluvirin), Q2038 (Fluzone), Q2039 (influenza NOS) referenced for intramuscular formulations

Administration guidanceInfluenza product listings specify intramuscular formulations for individuals 3 years and older (see Q-code comments)

Osteoporosis screening age change (from 50 to 40) — publication history update

Osteoporosis screening age updateScreening age changed from 50 to 40 (policy publication history update effective 01/01/26)

Applicable servicesBone density screening covered when billed with listed CPT and ICD-10 codes for persons age ≥40

Coding examplesProcedure codes listed include 76977, 77078, 77080, 77081, 77085, 77086; HCPCS G0130

Billing Rule

Administration codes for RSV monoclonal antibody

When administering respiratory syncytial virus (RSV) monoclonal antibodies, report both the product code and the appropriate administration code. Administration codes 96380–96381 are listed for RSV monoclonal antibody seasonal doses; also use applicable vaccine administration CPT/HCPCS (e.g., 96380/96381, G0008/G0009 as applicable) when counseling or vaccine-style administration reporting is required.

RSV product codes referenced: 90380, 90381, 90382
Administration codes: 96380, 96381
When counseling/documentation mimics vaccine administration, consider G0008/G0009 reporting where appropriate and supported.

Billing Rule

Colonoscopy billing requirements

Screening colonoscopies must be billed with the screening diagnosis in the primary position. Use CPT/HCPCS 00812 for screening colonoscopy; if the procedure converts to diagnostic, use 00811. Inpatient and emergency room colonoscopies are excluded from preventive benefit adjudication. Cologuard (81528) and Cologuard Plus (0464U) are covered ages 45–75 once every 3 years.

Use primary-position preventive diagnosis codes for screening claims
Use 00812 for screening colonoscopy; 00811 if converted to diagnostic
Inpatient and ER colonoscopies are not covered as preventive
Cologuard (81528) / 0464U: ages 45–75, q3 years

Billing Rule

Modifier requirements for preventive services

Modifier requirements: when a preventive service is billed with an additional E&M service, append modifier 25 to the E&M. Modifier 33 may be reported but is not determinative of preventive benefit unless explicitly indicated in the policy comments.

Append modifier 25 when billing E&M separately with a preventive service
Modifier 33 may be reported but is not solely used to determine preventive benefit

Note

No explicit additional provider actions noted

No explicit additional provider actions (e.g., step therapy, unique denials) are specified in these chunks beyond the listed billing, documentation and prior authorization rules.

No further step therapy or explicit denials listed in these source chunks.

Denial Risk

Code removal may trigger denial

Codes removed or retired in publication updates may result in claim denials if submitted after removal. Confirm you are using currently valid procedure and diagnosis codes per the policy's publication history before claim submission.

Review publication history and effective dates before billing
Do not submit removed/retired codes (may be denied)

Documentation Required

BP monitor documentation and limits

Home blood pressure monitor (A4660, A4663, A4670) coverage requires a physician order and is limited to one device per 36 months. Ensure documentation (physician order and medical record support) is maintained and submitted when requested.

Affected HCPCS: A4660, A4663, A4670
Limit: one device per 36 months
Physician order and supporting documentation required

Documentation Required

Breastfeeding equipment limits

Breastfeeding equipment limits: lactation support code 99502 is limited to one visit every 8 rolling months. Manual (E0602) and electric (E0603) pumps are purchase items and may have purchase frequency limits; hospital grade pumps (E0604) are rental items limited to a 3-month rental period after which the pump must be returned to the vendor. Purchase frequency and vendor return requirements apply.

Lactation visit 99502: limit 1 per 8 rolling months
E0602, E0603: purchase items; frequency limits may apply
E0604: rental for 3 months then return to vendor; purchase frequency limits may apply

Billing Rule

Use updated codes

Providers must submit the currently valid, active procedure and diagnosis codes as updated in the policy publication history. Periodic code additions and removals are listed in the publication history — verify codes (including HIV/J codes, immunization codes, RSV and others) before billing.

Check publication history for recent code changes (examples: J0738, J0752 added; RSV codes 90380–90382; administration codes added)
Do not bill with removed codes after their removal date

Benefit determination

Modifier 33 is not used to determine Preventive Care benefit applicability unless specifically indicated in the comments; coverage is based on listed procedure and diagnosis codes and instructions

Provider actionProviders may report Modifier 33 but must follow the policy's listed codes and Preventive Benefit Instructions for benefit determination

Covered immunization definition — not excluded by Certificate of Coverage and ACIP/FDA recommended

Covered immunization criteriaAn immunization not excluded by the Certificate of Coverage is considered covered if it has FDA approval and explicit ACIP recommendations published in the CDC MMWR

Implementation timingImplementation of ACIP recommendations typically occurs within 60 days after publication in the MMWR

Exclusion caveatImmunizations excluded by the Certificate of Coverage remain not covered even if FDA-approved/ACIP-recommended

ICD-10 immunization code (Z23) reference and related billing guidance

ICD-10 code for immunizationsZ23 (Encounter for immunization) is the ICD-10 code referenced for immunizations

Billing position requirementMany immunization administration or counseling codes must be billed with Z23 (or Z71.85 where specified) in the primary position

Related entriesZ23 is referenced across immunization administration definitions and required diagnosis code lists

LAIV3 / LAIV4 influenza vaccine definitions and code linkage

LAIV definitionsLAIV3 and LAIV4 are live attenuated influenza vaccines for intranasal use (e.g., Flumist®); formulations linked to CPT entries such as 90660/90662/90671 depending on formulation

Route and exampleAdministered intranasally; product example Flumist (90660 series)

Coding linkageLAIV entries are associated with CPT vaccine codes listed in the immunization code tables

IIV4 / aIIV4 influenza vaccine definitions and code linkage

IIV4 / aIIV4 definitionInactivated influenza vaccine, quadrivalent (IIV4) and adjuvanted quadrivalent (aIIV4) are intramuscular formulations with varying dosages and adjuvanted options

Product examplesProducts include Afluria, Fluarix, Fluzone and specific CPT codes 90685-90689 and 90686 etc.

Route and dosageAdministered intramuscularly with 0.25 mL or 0.5 mL dosage forms referenced in product comments

Influenza intramuscular formulations and Q-code mapping (Fluvirin, Fluzone examples)

Intramuscular influenza formulationsListing includes split virus intramuscular influenza vaccines (e.g., Fluvirin, Fluzone) for individuals 3 years and older

Q-code mappingQ2037 (Fluvirin) and Q2038 (Fluzone) are Q-codes referenced for these intramuscular influenza vaccines

Use noteQ2039 used for influenza vaccine not otherwise specified

Added immunization procedure codes 90611 and 90622 and added age criteria for codes 90670, 90671, 90677, 90684, 90732; removed J1810 from Voluntary Sterilization.

07/16/25code_addition

Added immunization codes 90382, 90612, 90613, 90631, 90635 and COVID-19 vaccine code 91323 under Immunizations.

08/14/25code_removal

Removed immunization code 90631 (previously added 07/16/25) from the Immunizations list.

11/01/25code_addition

Added administration/supply code A4288 under Breastfeeding Interventions and added J0738 and J0752 under HIV/HIV PrEP with prior authorization requirements (publication-history entry continues into 11/01/25).

01/01/26administrative_updateLatest

Added immunization administration/counseling codes 90481, 90482, 90483, 90484 to Immunizations and performed broader updates to immunization procedure/administration lists.

01/01/26code_additionLatest

Added multiple breast cancer screening procedure codes including 19081–19086, 19100–19101, 19499, 76641–76642, 77046–77049, 77053–77054, 77061–77066, 77065–77066, 88305, and G0279 to Breast Cancer Screening Mammogram and Pathology lists.

01/01/26diagnosis_code_additionLatest

Added numerous breast cancer screening diagnosis codes (C50.011–C50.929, C79.81, D05.00–D05.92, D24.1–D24.9, D48.60–D48.62, N60.01–N63.42, N64.0–N64.9, R92.0–R92.43, Z12.31, Z12.39, Z15.01, Z15.05, Z42.1, Z44.30–Z44.32, Z80.3, Z85.3, Z85.4A, Z86.00A) for Breast Cancer Screening Pathology.

Billing Rule

Publication history shows removed procedure codes — do not bill removed codes

Several specific procedure codes were removed in the publication history; providers must avoid billing with removed codes and follow the updated code lists.

Examples of removed codes listed in publication history include 90630, 90654, 0500T, J1810 and the later removal of 90631.