Coding Guidance
Nirsevimab is administered to newborns and infants under 8 months of age during their first RSV season and again in the second RSV season to children up to 19 months of age who remain vulnerable to severe RSV disease.
Product Codes
Report codes 90380–90381 based on the dose administered: 0.5mL or 1.0 mL.
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 (report 2 units when 2 mL is administered for the second-year dose)
Administration Code
Per CPT guidelines, Report the administration of nirsevimab with code 96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional or 96381 administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection.
Code selection is based on whether a physician or QHP provided counseling on the same date as the administration of nirsevimab. If counseling was not performed on the date of administration, 96381 is the correct code to report. Do not report immunization administration codes 90460–90461 or 90471– 90472 for the administration of nirsevimab, as these codes are limited to administering vaccine and toxoid products.
Vaccines for Children (VFC) Guidelines
To ensure appropriate payment when nirsevimab is provided through the VFC program, it is recommended to review the Medicaid payment guidelines, which can vary on a state-by-state basis.
Diagnosis Codes
Administration of nirsevimab is not reported with Z23 Encounter for immunization. Z23 is specific to immunization related to vaccines. While nirsevimab is categorized as a monoclonal antibody by CPT, ICD10 CM’s index guides us to code Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV).
Coding Vignettes
- A 2-day-old patient weighing 3 kg was born during the RSV season. The hospitalist provided counseling on RSV prevention, including the risks and benefits of receiving nirsevimab. The family's questions are answered and documented, and the newborn receives nirsevimab 0.5 mL before hospital discharge.
Coding Tip:
Inpatient counseling for nirsevimab is bundled into any E/M service provided on that date. Since the vignette shows no other billable services, a claim should not be filed by the hospitalist for counseling for nirsevimab.
- A 6-month-old previously healthy patient is seen in the office with a 2-day history of cough and runny nose and started today with a fever of 100.1, and after an exam, is diagnosed with a URI. The mother wants to know what else she could do to protect her baby from getting sick since the fall season is starting. The mother is counseled for 20 minutes about the recommendations for flu, COVID-19 vaccines, and nirsevimab. All her questions were answered, and the baby is scheduled to return the following week for a well-child check.
CPT codes:
99213-25 Office or other outpatient visit for the E/M of an established patient, requiring straightforward medical decision-making.
99401 Preventive medicine counseling provided to an individual; approximately 15 minutes.
Coding Tip:
Modifier 25 is required on 99213 to report codes 99213 and 99401 together.
- A 2-month-old established patient born prior to the start of the RSV season is seen in the office for a well exam. The patient is up to date with vaccines and will be receiving the recommended 2-month vaccines. In addition, the provider counsels the mother about nirsevimab. All of the mother’s questions were answered, and she would like to proceed with the recommendations.
CPT codes:
99391-25 Periodic comprehensive preventive medicine reevaluation and management of an established patient; infant (age younger than 1 year)
90723 Diphtheria, TT, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for IM use
90648 Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for IM use
90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for IM use
90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for IM use
90460 IM through 18 yrs., any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered = 3 units
90461 IM administration through 18 yrs., any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered = 4 units
96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional = 1 unit
Coding Tip:
Modifier 25 is required on 99391 to report codes 99391 and 90460, 90461, and 96380
together.
- An 18-month-old established patient with a history of severe immune compromise presents for a well-child visit. A preventive service is provided, including age-appropriate developmental screening. The physician also counsels on RSV prevention and discusses the risks and benefits of receiving nirsevimab. All of the family’s questions are answered and documented. The patient receives nirsevimab 200 mg (2 separate injections of 100 mg each) via intramuscular injection.
CPT codes:
99392-25 Periodic comprehensive preventive medicine reevaluation and management of an established patient; early childhood (age 1 through 4 years) including a 25 modifier.
96110 Developmental screening (e.g., developmental milestone survey, speech, and language delay screen), with scoring and documentation, per standardized instrument
90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for IM use = 2 units
96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional = 1 unit
Coding Tip:
Modifier 25 is required on 99392 to report codes 99392 and 96380 together.
- A 7-month-old established patient presents for a scheduled nirsevimab injection. Counseling was provided by the physician at the well-child visit 2 weeks ago. The mother had additional questions that the RN answered. The mother agrees to proceed with the administration of nirsevimab.
CPT codes:
90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for IM use
96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection= 1 unit
Coding Tip:
Additional counseling provided by RN and subsequent administration of nirsevimab does not support reporting an additional E/M code such as 99211. To report any E/M, a condition must be evaluated and managed; for coding purposes, immunization counseling does not equate to the management of a condition.
Payment Tips
Payment policies vary by payer and your contract with them. Contracts with payers should be reviewed regarding payment for nirsevimab. Include a provision in the contract for the health plan not to pay less than the actual invoice plus related practice expense costs. In addition to the payment for the vaccine and related expenses, make sure there is payment for administration, which is a separate expense. For information on the total direct and indirect costs of immunizations, see the AAP Business Case for Pricing Vaccines.
As per the Affordable Care Act (ACA), payers have 24 months following ACIP recommendations to recognize and pay for new vaccines. ACIP recommended nirsevimab on 8-3-2023. The AAP will notify the major national health plans about the recommendations and urge timely benefits coverage and appropriate payment for the vaccine and administration.
We encourage you to contact your payers and get their payment policies on reporting nirsevimab and your contract details for payment of immunizations in writing.
AAP Payment Advocacy for Nirsevimab
To ensure all infants are protected against RSV the AAP is urging commercial and public insurers to appropriately pay for nirsevimab based on the 2024 increase in product costs. The AAP also advocates for reducing administrative burden to practices related to prior authorization, maternal medical record requests, and inappropriate codes used to report nirsevimab administration. The following letters were provided to payers in September 2024 and may be beneficial for use when appealing claim denials related to the product and administration of nirsevimab.
Nirsevimab Prior auth and Correct codes
To assist in our advocacy efforts please report to us any contradictions to CPT guidelines that appear in payers coding guidance. Please send us their payment policy, and denials of payment to the coding hotline with an attachment of the documents. All patient information must be redacted as the AAP is not a HIPAA-covered entity.
Payers must comply with the ICD-10-CM and CPT coding conventions and guidelines as part of the HIPAA Administrative Simplification Act of 19 9 6. CMS is responsible for overseeing compliance with the act; for more information on how to resolve compliance issues with payers, review the ASSET tool guidelines.
Additional Information
Visit our Practice Management page for resources related to coding and payment.
AAP News article on coding for nirsevimab
Last Updated
11/18/2024
Source
American Academy of Pediatrics