How to code RSV antibody injections and vaccines

The Centers for Medicare & Medicaid Services (CMS) has retroactively added two new CPT codes for respiratory syncytial virus (RSV) monoclonal antibody administration to the Medicare Physician Fee Schedule, effective for dates of service on and after Oct. 6, 2023. The new codes are as follows: 

• 96380 – Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional,
• 96381 – Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection.

RSV monoclonal antibody product codes are in CPT’s “Immune Globulins, Serum or Recombinant Products” section. They are not technically vaccines, so you should not report them with traditional vaccine administration codes (e.g., 90460, “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered”). Likewise, you should report diagnosis code Z29.11, “Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV)” with these products, rather than Z23, “Encounter for immunization.”

In the non-facility (e.g., office) setting, Medicare allows $22.27 for 96380 and $19.32 for 96381 (that’s the national average, not geographically adjusted). You may use either code to report administration of RSV monoclonal antibody.

Report the monoclonal antibody product itself with one of these two CPT codes:

• 90380 – Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use,
• 90381 - Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use.

As noted, these products are not vaccines, and they are typically administered to children rather than adults. There are different codes for reporting the available RSV vaccines (currently recommended for adults age 60 and up, as well as pregnant women).

Report the vaccines with the following codes, depending on the product:

• 90678 - Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use (adults 60 years and older, plus pregnant patients at 32–36 weeks gestation),
• 90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (adults 60 years and older),
• 90683 Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use (adults 60 years and older).

Report administration of RSV vaccines with the appropriate code for vaccine administration, such as 90471, “Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).”

Some payers may ask you to append modifier 33 to the administration code to indicate that this was part of a preventive service and not subject to patient cost sharing. Check with your most common payers about their expectations in this regard.

Medicare covers the RSV monoclonal antibody under Part D. You can get more RSV shot information for your Medicare patients on the CMS website. You can also find RSV vaccination recommendations and updated clinical guidance on RSV on the AAFP website.

— Kent Moore, AAFP Senior Manager, Payment Strategies

Posted on Feb. 5, 2024