Immunization Coding for Obstetrician-Gynecologists

Immunizations form an important part of comprehensive healthcare for women. Under the Patient Protection and Affordable Care Act (ACA), all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) must be provided without any cost-sharing requirement, meaning no copay is charged for children, adolescents, or adults. 

To see exactly which vaccines are included, you can review the ACA’s covered vaccine list.

Outlined below are frequently used ICD-10 diagnosis codes and CPT/HCPCS codes connected with immunizations. These lists are not exhaustive, and in many cases, additional code characters will be necessary for accurate selection. 

For correct coding and usage, it is important to consult the latest official references, such as the ICD-10-CM manual, ACOG’s OB/GYN Coding Manual, the AMA’s Current Procedural Terminology Professional Edition, and HCPCS coding resources. Keep in mind that correct code assignment may depend on statutes, regulations, or payer-specific policies, and coding outcomes can differ among insurers.

This guide addresses the following areas:

• Reimbursement for vaccines
• Medicare coverage
• Medicaid coverage
• The Vaccines for Children (VFC) Program
• Commercial and private insurance plans

Reimbursement for Vaccinations

Payment for vaccines depends on the specific payer. Always review the terms of your payer contract for clarification.

Medicare

Medicare Part B does not usually cover vaccines unless they are required for treating an injury or direct exposure to a disease (e.g., tetanus after an injury or rabies after exposure). The ICD-10-CM code reported must reflect the condition or exposure. Preventive vaccines currently included under Medicare Part B are influenza, pneumococcal (both conjugate and polysaccharide), Hepatitis B, and COVID-19.

Influenza Vaccine

Medicare generally reimburses one influenza vaccination per year. If medical necessity requires additional doses, those will also be covered. When both influenza and pneumococcal vaccines are administered during the same visit, report diagnosis code Z23.

Pneumococcal Vaccine

Coverage typically allows for one pneumococcal vaccination in a patient’s lifetime. Revaccination is permitted when the patient is at high risk of severe infection or likely to experience a rapid decline in antibody levels. A minimum of five years must pass before the revaccination is reimbursed.

Hepatitis B Vaccine

This vaccine is covered only for Medicare beneficiaries considered at the highest risk or at risk for a rapid decrease in antibodies. High-risk groups include individuals with functional or anatomic asplenia, HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic kidney failure, nephrotic syndrome, or other immunosuppressive conditions.

Medicare Part D Coverage

Preventive vaccines not included in Part B fall under Medicare Part D, the prescription drug benefit. Most beneficiaries with Part D coverage are eligible for a wide range of routine immunizations.

Medicaid

Medicaid provides reimbursement for standard immunizations in eligible individuals under the age of 21. Coverage is offered through two separate programs:

• Ages 19–20: These patients receive routine vaccines through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This initiative is a public health service for low-income and medically underserved populations, administered at the state level. For details, providers should contact the specific state Medicaid office.
• Ages 18 and younger: These patients obtain their vaccines through the state-run Vaccines for Children (VFC) Program, outlined in the next section.

Vaccines for Children (VFC) Program

The Vaccines for Children (VFC) initiative supplies vaccines at no cost to physicians who treat qualifying children. The program is overseen nationally by the CDC through its National Immunization Program. To secure vaccines, the CDC contracts directly with manufacturers at discounted pricing.

Children are considered eligible for VFC if they meet any of the following conditions:

• Enrolled in Medicaid
• Age 18 years or younger
• Lack health insurance
• Identified as Native American or Alaska Native
• Have health insurance that does not include immunization benefits (in such cases, the child must receive vaccines at a federally qualified health center or a rural health clinic)

The program ensures vaccination against the following illnesses:

• Diphtheria
• Haemophilus influenzae type b
• Hepatitis A
• Hepatitis B
• Human papillomavirus (HPV)
• Influenza
• Measles
• Meningococcal disease
• Mumps
• Pertussis (whooping cough)
• Pneumococcal disease
• Poliomyelitis
• Rotavirus
• Rubella
• Tetanus
• Varicella (chickenpox)

Private/Commercial Plans

Under the Affordable Care Act, most private health insurance policies, including marketplace plans, are required to cover certain vaccines at no cost to the patient, as long as they are given by an in-network provider. This applies even when the patient has not yet met their annual deductible.

Vaccines commonly included without cost-sharing are:

• Hepatitis A
• Hepatitis B
• Herpes Zoster
• Human Papillomavirus (HPV)
• Influenza
• Measles, Mumps, Rubella (MMR)
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria, Pertussis (Tdap)
• Varicella

Providers should always check the individual’s insurance coverage for guidance on billing and coding requirements, as well as any restrictions related to same-day billing for evaluation and management services.

Coding for Vaccinations

ICD-10-CM Diagnosis Codes for Vaccination Services

Diagnosis codes for vaccination encounters are located within the Z code category of ICD-10-CM, which covers Factors Influencing Health Status and Contact With Health Services. When a patient is seen for a specific illness or symptom, both the diagnosis for that condition and the vaccination-related code should be reported.

Vaccination-related codes are generally grouped into the following categories:

• Potential health hazards related to communicable diseases for patients exposed to, or in contact with, a communicable disease
• Encounters for inoculations and vaccinations for the preventive administration of vaccines
• Encounters where a planned immunization was not completed

Table 1 

Lists the diagnosis codes most frequently used when documenting vaccination encounters for individuals with possible health risks due to communicable diseases. Note: this excludes carrier status of infectious disease (Z22.-), current infectious or parasitic disease diagnoses (Z22), and personal history of infectious or parasitic diseases (Z86.1-).

Common Z Codes for Vaccination Encounters

• Z20 - Contact with and (suspected) exposure to communicable diseases
  • Z20.1 - Tuberculosis
  • Z20.3 - Rabies
  • Z20.4 - Rubella
  • Z20.82 - Contact with and (suspected) exposure to other viral communicable diseases
    • Z20.820 - Varicella
    • Z20.828 - Contact with and (suspected) exposure to other viral communicable diseases
  • Z20.81-* - Contact with and (suspected) exposure to other bacterial communicable diseases
    • Z20.811 - Meningococcus
  • Z20.9 - Contact with and (suspected) exposure to unspecified communicable diseases
• Z23 - Encounter for immunization
• Z51.89 - Encounter for other specified aftercare
• Z41.8 - Encounter for other procedures for purposes other than remedying health state

Table 2: Immunization Not Carried Out and Underimmunization Status (Z28 Codes)

• Z28 - Immunization not carried out and underimmunization status
  • Z28.0 - Immunization not carried out because of contraindication
    • Z28.01 - Due to acute illness of patient
    • Z28.02 - Due to chronic illness or condition of patient
    • Z28.03 - Due to immunocompromised state of patient
    • Z28.04 - Due to patient allergy to vaccine or component
    • Z28.09 - Due to other contraindication
  • Z28.1 - Immunization not carried out because of patient decision for reasons of belief or group pressure
  • Z28.20 - Immunization not carried out because of patient decision for unspecified reason
  • Z28.21 - Immunization not carried out because of patient refusal
  • Z28.29 - Immunization not carried out because of patient decision for other reason
  • Z28.81 - Immunization not carried out due to patient having had the disease
  • Z28.82 - Immunization not carried out because of caregiver refusal
  • (Excludes 1: caregiver refusal based on religious belief - Z28.1)
  • Z28.83 - Immunization not carried out due to unavailability of vaccine
  • Z28.89 - Immunization not carried out for other reason

Current Procedural Terminology (CPT) and Medicare Coding for Vaccinations

Vaccination Procedures

A vaccination service includes two separate elements:

1. Administration of the vaccine
2. The vaccine product (drug) itself

Administration may be performed by an obstetrician–gynecologist or another qualified health care professional. When both the vaccine product and its administration are provided in the physician’s office, a code must be reported for each one for the vaccine itself and another for its administration.

Codes for Vaccine Administration

Administration codes are selected based on the method and route used to deliver the vaccine. Both Medicare and CPT rely on the same coding system to report most vaccine administrations.

(Refer to Table 3 for CPT codes covering administration of single or combination vaccines/toxoids.)

Table 3: CPT Codes for Vaccine Administration (Single or Combination Vaccine/Toxoid)

• 90460 - Primary administration by percutaneous, intradermal, subcutaneous, or intramuscular route.
  • Reported for each vaccine given when the physician provides counseling.
  • Patient must be 18 years or younger.
• 90461 - Each additional component administered by percutaneous, intradermal, subcutaneous, or intramuscular route.
  • Used in conjunction with 90460.
  • Physician provides counseling.
  • Patient must be 18 years or younger.
• 90471 - Primary injection (percutaneous, intradermal, subcutaneous, or intramuscular).
  • Report only one primary administration code per encounter.
• +90472 - Each additional injection (percutaneous, intradermal, subcutaneous, or intramuscular).
  • Reported for secondary or subsequent vaccine administrations.
  • Only reported in conjunction with 90460, 90471, or 90473.

Note: Medicare requires the use of specific HCPCS codes for administration of influenza, pneumococcal, or hepatitis B vaccines. Some commercial insurers also accept these codes. (See Table 4 for details.)

Table 4: Medicare HCPCS Codes for Vaccine Administration

• G0008 - Administration of influenza vaccine by injection (Primary service)
• G0009 - Administration of pneumococcal vaccine by injection (Primary service)
• G0010 - Administration of hepatitis B vaccine by injection (Primary service)

Medicare does not assign unique HCPCS codes for the administration of other vaccines. In those situations, the correct CPT administration code should be reported.

Codes for the Vaccine Drug Product

Both CPT and Medicare require the use of CPT codes 90476–90749 to identify the vaccine products themselves.

Tables 4 through 7 summarize vaccine coding and administration rules under CPT and Medicare guidelines.

Administration Codes by Patient Age

For patients under 18 years of age:

• 90460 - Administration of vaccine (any route) with physician or qualified professional counseling, first or only component of each vaccine/toxoid
• +90461 - Each additional vaccine or toxoid component, listed separately in addition to the primary procedure

For patients 18 years and older

• 90471 - Administration of vaccine (percutaneous, intradermal, subcutaneous, or intramuscular), first or only vaccine (single or combination)
• +90472 - Each additional vaccine (single or combination), listed separately in addition to the primary procedure
• 90473 - Administration of vaccine by intranasal or oral route, first or only vaccine (single or combination)
• +90474 - Each additional vaccine (single or combination) administered intranasally or orally, listed separately in addition to the primary procedure

Table 5: Vaccines Commonly Administered to Adolescents and Adults

(Always report both an administration code and a vaccine product code)

• Hepatitis A (HepA), adult dosage, intramuscular
  • Product code: 90632
  • CPT administration: 90471–90472
  • Medicare administration: 90471–90472
• Hepatitis A (HepA), pediatric/adolescent dosage, 2-dose schedule, intramuscular
  • Product code: 90633
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Hepatitis A (HepA), pediatric/adolescent dosage, 3-dose schedule, intramuscular
  • Product code: 90634
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Hepatitis B (HepB), adolescent dosage, 2-dose schedule, intramuscular
  • Product code: 90743
  • CPT administration: 90460–90472
  • Medicare administration: G0010
• Hepatitis B (HepB), pediatric/adolescent dosage, 3-dose schedule, intramuscular
  • Product code: 90744
  • CPT administration: 90460–90472
  • Medicare administration: G0010
• Hepatitis B (HepB), adult dosage, 3-dose schedule, intramuscular
  • Product code: 90746
  • CPT administration: 90471–90472
  • Medicare administration: G0010
• Hepatitis B (HepB), adult dosage, 2-dose schedule, intramuscular
  • Product code: 90739
  • CPT administration: 90471–90472
  • Medicare administration: G0010
• Hepatitis B (HepB), dialysis or immunosuppressed patient dosage, 3-dose schedule, intramuscular
  • Product code: 90740
  • CPT administration: 90471–90472
  • Medicare administration: G0010
• Hepatitis B (HepB), dialysis or immunosuppressed patient dosage, 4-dose schedule, intramuscular
  • Product code: 90747
  • CPT administration: 90471–90472
  • Medicare administration: G0010
• Hepatitis A and Hepatitis B (HepA–HepB), adult dosage, intramuscular
  • Product code: 90636
  • CPT administration: 90471–90472
  • Medicare administration: 90471–90472
• Human Papillomavirus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3-dose schedule, intramuscular
  • Product code: 90649
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472

Additional Vaccines Commonly Administered to Adolescents and Adults

• Human Papillomavirus (HPV) vaccine, types 16 and 18 (bivalent), 3-dose schedule, intramuscular
  • Product code: 90650
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Human Papillomavirus (HPV) vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58 (nonavalent, 9vHPV), 2- or 3-dose schedule, intramuscular
  • Product code: 90651
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135 (MPSV4), subcutaneous
  • Product code: 90733
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Meningococcal conjugate vaccine, serogroups A, C, W, Y (MenACWY-D or MenACWY-CRM), intramuscular
  • Product code: 90734
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Pneumococcal conjugate vaccine, 13-valent (PCV13), intramuscular
  • Product code: 90670
  • CPT administration: 90460–90472
  • Medicare administration: G0009
• Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed dosage, for individuals 2 years or older, subcutaneous or intramuscular
  • Product code: 90732
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Tetanus and diphtheria toxoids (Td), preservative-free, for individuals 7 years or older, intramuscular
  • Product code: 90714
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Tetanus, diphtheria, and acellular pertussis vaccine (Tdap), for individuals 7 years or older, intramuscular
  • Product code: 90715
  • CPT administration: 90460–90472
  • Medicare administration: 90471–90472
• Varicella virus vaccine (VAR), live, subcutaneous.
  • Product code: 90716
  • CPT administration: 90460–90472
  • Medicare administration: 90460–90472
• Varicella-zoster immune globulin, human, intramuscular
  • Product code: 90396
  • CPT administration: 90460–90472
  • Medicare administration: 96372
• Zoster (shingles) vaccine (HZV), live, subcutaneous injection
  • Product code: 90736
  • CPT administration: 90471–90472
  • Medicare administration: 90471–90472
• Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, intramuscular
  • Product code: 90750
  • CPT administration: 90471–90472
  • Medicare administration: 90471–90472

Table: 6 - Coding for Influenza Vaccines

• Influenza virus vaccine, trivalent, split virus, preservative free, 0.25 mL dosage, intramuscular
  • Product code: 90655
  • CPT administration: 90460–90472
• Influenza virus vaccine, trivalent, split virus, preservative free, 0.5 mL dosage, intramuscular
  • Product code: 90656
  • CPT administration: 90460–90472
• Influenza virus vaccine, trivalent, split virus, 0.25 mL dosage, intramuscular
  • Product code: 90657
  • CPT administration: 90460–90472
• Influenza virus vaccine, trivalent, split virus, 0.5 mL dosage, intramuscular
  • Product code: 90658
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, derived from cell culture, subunit, preservative and antibiotic free, 0.5 mL dosage, intramuscular
  • Product code: 90674
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, recombinant hemagglutinin (HA) protein only, preservative and antibiotic free
  • Product code: 90673
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.25 mL dosage, intramuscular
  • Product code: 90685
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, split virus, preservative free, 0.5 mL dosage, intramuscular
  • Product code: 90686
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, live, intranasal
  • Product code: 90672
  • CPT administration: 90460–90472
• Influenza virus vaccine, quadrivalent, cell culture-based, inactivated, subunit, preservative and antibiotic free, 0.5 mL dosage, intramuscular
  • Product code: 90756
  • CPT administration: 90460–90472

Table 7. Medicare Coding for Vaccines

• Influenza virus vaccine, split virus, intramuscular, for individuals 3 years of age and older
  • Product code: Q2035
  • Medicare administration code: G0008
• Influenza virus vaccine, split virus, intramuscular, for individuals 3 years of age and older (not otherwise specified)
  • Product code: Q2036
  • Medicare administration code: G0008
• Influenza virus vaccine, split virus, intramuscular, for individuals 3 years of age and older (additional formulation)
  • Product code: Q2037
  • Medicare administration code: G0008
• Influenza virus vaccine, split virus, intramuscular, for individuals 3 years of age and older (unspecified brand)
  • Product code: Q2038
  • Medicare administration code: G0008
• Influenza virus vaccine, split virus, not otherwise specified
  • Product code: Q2039
  • Medicare administration code: G0008

Table 8. Coding for RSV Vaccines and Monoclonal Antibody Administration

Administration of Monoclonal Antibody (RSV):

• Administration of respiratory syncytial virus monoclonal antibody, intramuscular injection, with counseling by physician or qualified health professional
  • Product code: 90380
  • Administration code: 96380
• Administration of additional RSV monoclonal antibody dose
  • Product code: 90381
  • Administration code: 96381

Vaccine Codes for RSV (Respiratory Syncytial Virus):

• Respiratory syncytial virus vaccine, recombinant, subunit, bivalent, intramuscular
  • Product code: 90678
  • Administration code: 90460–90480
  • Indications:
    • Infants < 8 months during RSV season
    • Children 8–19 months at increased risk of severe RSV disease during RSV season
• Respiratory syncytial virus vaccine, recombinant, subunit, adjuvanted, intramuscular
  • Product code: 90679
  • Administration code: 90460–90480
  • Indications:
    • Adults 60 years and older
    • Pregnant individuals (administered at 32–36 weeks gestation during RSV season)

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From ICD-10-CM diagnosis coding (Z codes) to CPT/HCPCS administration codes and payer-specific vaccine requirements, our team ensures accuracy and compliance at every step. With expertise in navigating Medicare Part B and Part D coverage, Medicaid’s EPSDT and VFC programs, as well as commercial plan guidelines under the Affordable Care Act, we help practices maximize reimbursement while avoiding costly errors.

Our specialists handle the entire immunization billing process, from vaccine product coding and administration reporting to payer-specific rules for influenza, pneumococcal, RSV, and COVID-19 vaccines. With BillingFreedom, healthcare providers can trust that their claims are processed efficiently, reimbursements are optimized, and compliance standards are fully met, allowing them to focus on patient care.

 

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