Learn about shingles vaccine CPT codes for accurate billing and reimbursement. Get details on the correct codes, insurance compliance, and claims processing.

As medical professionals, we usually encounter patients who are anxious about shingles. It is an infection caused by the varicella-zoster virus, the same virus that causes chickenpox. Although it is possible for anyone to have shingles, the risk factor increases as a person ages. Shingles involve a painful rash and blistering skin that can last for a few weeks.

For patients worried about the risk and expense of shingles, vaccination can be a comforting alternative. The various vaccines and insurance considerations can be confusing, though. In order to give our patients optimal care and efficiently run our practice, it’s important for us physicians to know the CPT codes for shingles vaccinations.

Here, we will describe the CPT coding for shingles vaccines and how it assists in making these necessary preventive treatments accessible and affordable to our patients.

What is meant by CPT codes?

When medical practitioners administer shingles vaccinations, they employ distinctive codes known as CPT codes to identify and bill the services. Shingrix and Zostavax vaccines have distinctive Shingles Vaccine CPT codes for each of them. The codes assist physicians to communicate effectively with insurers when they give a vaccine against shingles.

For example, the 90736 code is applied for the Zostavax vaccine, and the 90734 code is applied for a Shingrix injection. If doctors include these codes on claim forms, they can inform insurance companies precisely which vaccine was administered. This informs the insurers which service was rendered and pays the doctor appropriately.

Essentially, CPT codes avoid confusion and simplify the shingles vaccination billing process to make it clear and transparent. They are similar to distinct labels that make everything proceed in a perfect manner when dealing with medical billing.

How Are CPT Codes Used for Shingles Vaccine?

CPT codes are similar to a universal language that healthcare professionals and insurance providers use to speak about billing for shingles vaccines. Let’s examine more closely how these codes are utilized:

Help with the Identification of Vaccine Type

CPT codes such as 90750 and 90736 are used to specify what kind of shingles vaccine was administered. Insurance companies and medical records care about this information because it precisely informs them what vaccine was administered.

Helps with the Reimbursement Process

When health practitioners administer shingles vaccines, the providers utilize the CPT code in assisting them in reimbursement. The providers make use of codes such as 90750 or 90736, and after that, payers determine what they should compensate back. In this manner, providers receive money properly for their administered vaccines.

Help Track the Correct CPT Code Usage

CPT codes also assist in helping health practitioners monitor how many shingles vaccinations they’ve administered. Monitoring this is significant to determine vaccine coverage and identify potential outbreaks of diseases. Through the use of exact patient health information and the CPT code, health practitioners are able to capture all vaccine information accurately.

Common CPT Codes Used for Shingles Vaccine

For accurate billing of the shingles vaccine, two CPT codes are especially important: 90736 and 90750. These codes help both healthcare providers and insurance companies understand what vaccine was given, making sure that the reimbursement process is smooth and correct for this essential vaccine.

CPT Code 90750

CPT code 90750 is reserved for administration of Shingrix, the vaccine that protects against the excruciating rash and blisters of the varicella-zoster virus, the same virus that causes chickenpox. The following are some of the most important points regarding this code:

• What It Covers: The code covers the cost of the vaccine as well as the professional fee for administering it. Every dose is coded separately.
• Exclusive Use: 90750 is exclusively used for Shingrix. There are other codes for other vaccines, such as Zostavax.
• Modifiers: No modifier is required, but one can be added if more information is desired on the patient or where the vaccine was administered.
• Diagnosis Code: ICD-10 code Z23 (immunization visits) is usually combined with 90750 to indicate that the vaccine was administered intentionally.
• Vaccine Schedule: Shingrix is administered in two doses, the second 2–6 months after the first. Each dose is billed separately with 90750.
• Vaccine Design: Shingrix has a fragment of the varicella-zoster virus and an adjuvant to assist in stimulating the immune system. This design assists in developing immunity without exposing patients to a live virus.
• Effectiveness: Shingrix is greater than 90% effective at preventing shingles and persistent nerve pain in individuals 50 years and older.

CPT Code 90736

The CPT code 90736 is applied to report the administration of Zostavax, a live attenuated vaccine designed to protect against shingles—a painful rash caused by the varicella-zoster virus. The following are some key facts regarding this code:

• What It Covers: This code captures the cost of the vaccine and the fee charged to a healthcare practitioner to administer it. It covers a single dose of the vaccine.
• Reporting Separately: When you use 90736, report it separately from other services the patient is receiving on the same visit, such as an office visit or other vaccinations. This way, you will be paid properly.
• Avoid Confusion: Don’t confuse Zostavax (90736) with Shingrix (90750), which is another shingles vaccine. They are coded separately because they are two different products.
• Modifiers: Modifiers can be added to 90736 with additional information, e.g., the location where the vaccine was administered. However, you may not always have to use them.
• Verification: Confirm that the patient is a candidate and if any age guidelines, frequency restrictions, or other guidelines apply prior to administering Zostavax and submitting 90736. Coding needs to be correctly done to be paid for correctly.

Correct and Incorrect Usage of CPT Codes for Shingles Vaccine

Using the wrong CPT code for shingles vaccines can cause problems. It might lead to claims being rejected, unexpected medical bills for patients, and even audits that affect how much healthcare practices get paid. To avoid these issues, it’s crucial to always use the correct CPT code.

Case #1: Reporting Vaccine Units

What  Not to Do: Never report more than one unit of the Shingrix vaccine if only one is administered to a patient.

What to Do: Always report administration of one unit of the Shingrix vaccine. This provides correct billing and avoids confusion.

Case #2: Using CPT Code 90750 for Zostavax

What  Not to Do: Do not confuse shingles vaccine codes. For instance, using the code 90750 for Zostavax and not Shingrix can create issues.

What to Do: Always refer to a codebook to ensure that you’re entering the right code for the vaccine being administered. This ensures accuracy and avoids errors.

Case #3: Bundling with Other Services

What Not to Do: Do not bill the Shingrix vaccine together with other services such as other vaccinations or office visits. This may result in improper payments.

What to Do: Bill the Shingrix vaccine separately from other services using CPT code 90750. This will ensure that you receive proper payment.

Applying Modifiers to the Shingles Vaccine CPT Codes

There are times when you may have to use modifiers that are special when billing for shingles vaccines. That is the case if the vaccine is administered somewhere other than a physician’s office. Some examples are as follows:

• Urgent Care Facility: You would employ modifier 20.
• Inpatient Hospital: You would employ modifier 21.
• Outpatient Hospital: You would employ modifier 22.

For example, if a patient receives the shingles vaccine during an outpatient hospital visit, you could use a code such as 90736 with a modifier to identify where it was performed. This makes the billing process more accurate.

Conclusion

It’s crucial for patients and healthcare practitioners to be familiar with CPT codes for shingles vaccines. The two important codes, 90750 and 90736, are uniquely employed in reporting shingles vaccines. This aids in streamlining the process of billing and prevents healthcare providers from being incorrectly compensated for the vaccines they dispense.

By adhering to these standards and keeping up with the newest coding practices, we can continue to make shingles vaccines available and affordable for all those who require them.

For a hassle-free medical billing experience and to explore more healthcare coding insights, visit Keizer Technologies, where we simplify the complexities of medical billing and compliance.