The CPT code for Shingrix is explained in this blog along with the recommended dosage, administration schedule, and necessary billing procedures. The usage of CPT 90750 for the vaccine product, suitable administration codes, ICD-10 diagnosis coding, Medicare and commercial insurance regulations, NDC reporting, and documentation requirements are all described. Healthcare practices can avoid claim denials, guarantee compliance, and obtain appropriate reimbursement for shingles vaccinations by being aware of these requirements.
Shingrix is a recombinant zoster vaccine that protects against shingles (herpes zoster). This virus causes a painful rash as a result of the reactivation of varicella-zoster virus. The shingles disease can cause severe pain.. It is especially troubling for older adults and those with a weakened immune system and may cause severe nerve damage and skin rashes, along with long-lasting complications, such as postherpetic neuralgia, chronic pain, and other issues. Given the associated risks, Shingrix has been a cornerstone preventive care option for adults aged 50+ and for certain immunocompromised patients aged 19+.
Coding Shingrix is as much of a skill as clinically administering it. The completion of the CPT coding, cross-reference with the individual payer’s guidelines, and a detailed claims document, minimizes the possibility of a claim denial. This article centers on one Shingrix CPT code and offers insights on billing and documentation best practices, along with dosage and scheduling guidelines.
What Is Shingrix?
Shingrix is a non-live, recombinant adjuvant vaccine designed to trigger a strong immune response to the varicella-zoster virus safely and effectively. . It is also designated to treat beyond the basic shingles infection. Just like most recently designed and manufactured shingles vaccines, it also provides the best protection with the longest duration – a characteristic prominently included within its CDC (Centers for Disease Control and Prevention) provided endorsements.
Your primary audience is administrators and physicians engaged in risk and operations management who will appreciate the need for concise and clear communication in order to meet the organization’s requirements. The vaccine is not a live vaccine. Shingrix is not contraindicated for most immunocompromised individuals who may not have been candidates for prior shingles vaccines. The clinical characteristics affect the way the vaccine is billed and how it is documented in the medical record.
CPT Code for Shingrix Vaccine Product
Shingrix is a non-live, recombinant adjuvant vaccine designed to trigger a strong immune response to the varicella-zoster virus safely and effectively. . It is also designated to treat beyond the basic shingles infection. Just like most recently designed and manufactured shingles vaccines, it also provides the best protection with the longest duration – a characteristic prominently included within its CDC (Centers for Disease Control and Prevention) provided endorsements.
Your primary audience is administrators and physicians engaged in risk and operations management who will appreciate the need for concise and clear communication in order to meet the organization’s requirements. The vaccine is not a live vaccine. Shingrix is not contraindicated for most immunocompromised individuals who may not have been candidates for prior shingles vaccines. The clinical characteristics affect the way the vaccine is billed and how it is documented in the medical record.
Vaccine Administration CPT Codes
In addition to collecting payment for the vaccine, there is also a vaccine administration code that must be documented. 90471 is the most frequently documented code which states the administration of an immunization. If a patient, in the same visit, receives more than one vaccine, 90472 can be billed for each subsequent vaccine.
The administrative service expense that is attributed to the vaccine encompasses the prep work, the actual injection, and any counseling that may have been provided. If there is no administration code documented on the claim, it could be possible that there is an oversight of revenue, even if the vaccine itself was reimbursed correctly.
Dosage and Administration Schedule
Shingrix is a two-dose series where each dose is 0.5 mL given via intramuscular injection. The recommended schedule for the second dose is two to six months after the first dose. For immunocompromised patients, the second dose can be given as early as one month after the first dose. Each dose is billed separately with CPT 90750 and the corresponding administration code. Providers are restricted from billing for both doses on a single claim, unless both doses are administered on the same date of service, which is rare and generally not recommended.
ICD-10 Diagnosis Codes for Shingrix
Coding for diagnoses validates the reason why certain vaccines were given. For Shingrix, the most commonly used ICD-10 code is Z23 (Encounter for immunization) and this is recognized by most payers for claims pertaining to preventative vaccines.
There are instances where other diagnosis codes can be used, pertaining to patient factors that carry risk (e.g. immunocompromised). That said, Z23 in isolation is adequate for the Z23 to reimburse. Appropriate coding helps to get the right claim paid for the right reason and diminishes the chance of a claim not being paid.
Medicare Coverage and Billing Rules
Medicare usually covers Shingrix under Part D, the prescription drug plan, not under Part B. This is an important difference, since there is a separate process for Part D claims compared to other medical claims. Direct billing to Medicare Part D is not an option for most physician practices, which poses the need for the patient to get Shingrix from a pharmacy or for the practice to manage Shingrix under a pharmacy billing process. To avoid billing issues, it is recommended to check Shingrix Part D coverage and the patient’s cost before the vaccine is administered.
Commercial Insurance Billing
Shingrix is covered by most insurance companies as a preventive service for qualified patients. Here, the providers bill the vaccine using code CPT 90750 and for the administration use code 90471, plus Z23 for the diagnostic. Understanding the payer policies and benefits before submission will streamline the claim submission and reimbursement process.
National Drug Code (NDC) Reporting
Along with CPT codes, Shingrix vaccine claims for most payers are required to include a National Drug Code (NDC). This code shows the related drug company, the specific drug, and the size of the package. Claims may be missing, incorrectly coded, or denied for various reasons, but practices need to pay attention to the NDC. An 11-digit NDC must be included that describes the manufacturer and the product, along with the correct measuring unit and quantity.
Documentation Requirements
Meticulous documentation is directly related to patient care and billing. The medical record should include the vaccine name, the dosage, the route of administration, the lot number, the date of expiration of the vaccine, the injection site, the date of service, and the name of the person who administered the vaccine. Lastly, the record should note that the patient was given consent to receive the vaccine. Proper and complete documentation shows medical necessity, and assures legal and compliance safety, while protecting the practice when it comes to audit defense.
Modifier Use with Shingrix Codes
Detailed documentation is essential for both billing and patient care. A vaccine record should include the name of the vaccine, dosage, administration route, lot number, expiration date, injection site, date of service, and name of the service provider. In addition, documentation must include that the patient was given consent to receive the vaccine. Well-done and complete documentation proves the medical necessity of the service, meets legal and compliance standards, and protects the practice for audit defense.
Common Billing Errors
When billing for CPT 90750 and vaccine administration codes, modifiers are usually not required. However, if the administration of the vaccine is accompanied by a separate and distinct evaluation and management (E/M) service, performed on the same date, then modifier 25 will need to be added to the E/M code. In such instances, to justify modifier 25, documentation must be made showing that a service other than the vaccination was provided.
Reimbursement Considerations
There are a number of billing errors that could lead to delays or denials of Shingrix claims. These errors are billing for the vaccine product and not including a code for vaccine administration, billing to the wrong Medicare benefit, using the wrong or inappropriate diagnosis codes, and omitting NDC information. Staff training, coupled with internal audits, can assist your practice with identifying and rectifying these billing errors prior to the submission of claims.
Best Practices for Successful Shingrix Billing
For Shingrix billing to be successful, staff must check patient eligibility and coverage. Proper CPT, ICD-10, and NDC coding, along with thorough documentation, is essential. Staff should also understand Medicare Part D regulations. Increased process optimization, billing software, and standardization should decrease errors and improve revenue.
Conclusion
To achieve reimbursement and compliance, a practice must know what CPT code to use for Shingrix, what the dosage is, what the billing and documentation rules are. Practices reduce denial and receive payment faster using CPT code 90750 for the vaccine itself, plus the correct administration codes and the right supporting diagnosis codes.To enhance patient care, preventive immunization remains critical. Mastering the coding and billing for Shingix further supports clinical practice and the financial bottom line.
Make An Appintment With A2ZFAQs
The recombinant Zoster vaccine product Shingrix is reported using the claim CPT code 90750.
The code 90471, which is an administration code for vaccines, must be billed along with the product code.
The vaccine is administered twice, with the second dose scheduled for 2-6 months after the first dose.
Medicare D usually covers Shingrix, but Medicare Part B does not provide any coverage.
The code used is Z23, which in the ICD-10 is used for the documentation Encounter for immunization.