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Understanding the CPT codes for RSV vaccine and antibody injections is the first task for getting rightfully paid as a healthcare provider. When you append the right codes in your medical claims, they’ll get accepted on time. And incorrectly assigning CPT and other medical codes can result in practice audit, delayed payments, and more.
This ProcareMedEx guide covers the most common CPT codes for administering RSV vaccine for adults, children, and pregnant patients. But let’s dive in the basics first.
What Are CPT Codes?
Current Procedural Terminology (CPT) codes are procedure codes to identify diagnostic, medical, and surgical procedures and services. These codes act as a universal language in healthcare. And they are created and maintained by The CPT® Editorial Panel, authorized by the AMA Board of Trustees.
The CPT codes also identify the diagnosis and administration of RSV vaccine under public and private health insurance programs. These codes also help optimize medical billing processes, including claim submission and more.
The Most Common CPT Codes for RSV Vaccine
All these CPT codes are somehow related to diagnosing and treating diseases caused by respiratory syncytial virus (RSV), including the vaccine administration and the provider’s counseling.
- 96380
- 96381
- 90380
- 90381
- 90678
- 90679
- 90683
- 90471
Let’s dive into the details of these CPT codes now.
96380
96380 is used for the administration of a monoclonal antibody for respiratory syncytial virus (RSV) by intramuscular injection. It’s appended when a physician or another qualified healthcare professional also provided counseling related to the administration. This code showcases the seasonal dose of the monoclonal antibody and includes the additional step of providing counseling to the patient.
For example, take a scenario where a pediatrician sees a 6-month-old patient weighing 4.8 kg for an RSV prophylaxis visit. During this visit, the physician administers a 0.5 mL dose of nirsevimab (sold under the brand name “Beyfortus”) and provides detailed information on RSV, its prevention, and the importance.
The physician uses code 96380 to document both the administration of the monoclonal antibody and the counseling provided. When billing, append this CPT code for RSV vaccine (96380) with any relevant modifiers and the appropriate diagnosis code, Z29.11, to indicate prophylactic immunotherapy for RSV.
96381
CPT code 96381 is appended for the administration of a monoclonal antibody for RSV by intramuscular injection without the requirement for counseling at the time. Remember this code applies to the seasonal dose of the monoclonal antibody when the counseling was not part of the visit or occurred at a different time.
For example, if a 7-month-old patient receives a 1 mL dose of nirsevimab, the RSV vaccine, during a follow-up visit after the initial counseling provided two weeks earlier, the healthcare provider would use code 96381 to capture the administration of the monoclonal antibody.
Note that this code is used for documenting the administration event only. And the counseling is billed separately if applicable. The appropriate DX code, Z29.11, should also be reported alongside this administration code.
90380
CPT code 90380 represents the RSV monoclonal antibody product for a 0.5 mL seasonal dose intended for intramuscular use. This CPT code for RSV vaccine is specific to the product’s dosage and is used to report the administration of this quantity of the monoclonal antibody.
For example, when a 3-month-old infant weighing less than 5 kg is administered a 0.5 mL dose of nirsevimab during an RSV prophylaxis appointment, the healthcare provider would use code 90380 to bill for this specific dosage. Combine this CPT code for RSV vaccine dosage with the diagnosis code Z29.11.
90381
CPT code 90381 is used for the administration of a 1 mL dose of the RSV vaccine for intramuscular use. Append this code when giving the mentioned dose to the well-child patients, typically those weighing 5 kg or more.
For example, if a 6-month-old child patient weighing 6 kg receives a 1 mL dose of nirsevimab during their RSV prophylaxis visit, use code 90381 to indicate the administration of this dosage (1mL). Report this code along with the appropriate administration code (96380 or 96381) and the DX code, Z29.11.
90678
CPT code 90678 reports the bivalent RSV vaccine, preF, subunit, for intramuscular use. This RSV vaccine is recommended for adults aged 60 years and older, as well as pregnant patients between 32 and 36 weeks of gestation. It helps reduce the incidence and severity of RSV in older adults and pregnant women.
Append 90678 with the DX code (Z23) to reflect the patient’s need for the vaccine and the administration code 90471 to indicate the immunization service provided.
And if the payer requires, append modifier 33 to indicate the preventive service, which is exempt from cost-sharing. You can check with your most common payers to confirm if the modifier 33 is required.
90679
The CPT code for RSV vaccine Arexvy recombinant, subunit, adjuvanted, is 90679 for intramuscular use. This RSV vaccine is recommended for adults aged 60 years and older. For example, the provider would use this code if an elderly patient receives the recombinant RSV vaccine during a scheduled vaccination appointment.
Report 90679 with the administration code 90471, and the appropriate DX code to justify the vaccine administration.
90683
90683 is designated for the RSV vaccine Mresvia, mRNA lipid nanoparticles, for intramuscular use. This mRNA-based vaccine is recommended also for adults aged 60 years and older. For example, the provider would append the code 90683 with the administration code 90471 to reflect the scope of immunization. Again, include the relevant DX code that supports the patient’s eligibility for the vaccine.
90471
90471 is used for the administration of a single vaccine or combination vaccine/toxoid, including those administered intramuscularly. This CPT code covers the service of administering a vaccine and includes any related counseling and documentation.
Here’s the detailed summary of the code:
CPT code 90471, “Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)”.
This CPT code is relevant for reporting the administration of RSV vaccines, such as the bivalent subunit vaccine (CPT code 90678) designed for adults 60 years and older and pregnant patients at 32-36 weeks gestation.
For example, if an adult patient receives the RSV vaccine during a routine office visit, the provider would use code 90471 to bill for the administration of this vaccine. They would also use the administration code and the diagnosis code Z23 (“Encounter for immunization”) to showcase the vaccine administration was for immunization purposes.
And suppose if the vaccine administration is part of a preventive service, append the modifier 33 to indicate that the service is not subject to patient cost-sharing.
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