As nirsevimab is the first product of its kind, the AAP recognizes that prompt and appropriate payment for nirsevimab will be challenging in the first year of implementation. The current administration code is inadequate and does not take counseling, storage/handling, or reporting into consideration. The AAP is advocating for improved codes, as well as appropriate payment (see AAP letter to CDC/CMS Directors). 

Coding Guidance 

Nirsevimab is administered to newborns and infants once 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 

CPT codes 90380–90381 were approved by the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Editorial Panel in May 2023, released on June 30, 2023.  

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 

Follow state specifications for reporting the immunization when the immunoglobulin product is provided through the Vaccines for Children program. For example, report 90380 SL to indicate state-supplied product). 

Administration Code 

Report the administration of nirsevimab with code 96372 (injection, subcutaneous or intramuscular). Do not report immunization administration codes 90461–90462 or 90471–90472 for the injection of nirsevimab, as these codes are limited to the administration of vaccine and toxoid products. See examples of reporting administration of nirsevimab along with other services in the coding vignettes below. 

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). Using the appropriate diagnosis code is not only important for billing and claims payment, but it is also necessary for data collection and quality metrics.

Coding Vignettes 

  1. A 2-day-old patient weighing 3 kg was born during the RSV season. Counseling on RSV prevention was provided by the hospitalist, including the risks and benefits of receiving nirsevimab. All of the family's questions are answered and documented, and the newborn receives nirsevimab 0.5 mL prior to hospital discharge 
    • Coding Tip:
      1. Inpatient counseling for nirsevimab and any other medications or vaccines is bundled into any E/M provided on that date of service. Since the vignette shows no other billable services, a claim should not be filed by the hospitalist for counseling for nirsevimab.
  2. A 6-month-old previously healthy patient is seen in office with a 2-day history of cough and runny nose and today started with a fever of 100.1,and after an exam is diagnosed with a URI. . Mother would like to know what else she could do to protect her baby from getting sick since the fall season is starting. Mother is counseled for 20 minutes about the recommendations for flu, COVID vaccines, and nirsevimab. All her questions were answered, and we will discuss more when the baby returns next week for a well-child check.
    • CPT codes:
      1. 99213 Office or other outpatient visit for the E/M of an established patient, requiring straightforward medical decision-making. 
      2. 99401 Preventive medicine counseling provided to an individual; approximately 15 minutes
    • Coding Tip:
      1. Modifier 25 is required to report codes 99213 and 99401 together.
      2. Preventive medicine counseling codes are not reportable with well visit codes 99381-99385 and 99391-99395
  3. 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 mother’s questions were answered, and she would like to proceed with the recommendations.
    • CPT codes:
      1. 99391 Periodic comprehensive preventive medicine reevaluation and management of an established patient; infant (age younger than 1 year)
      2. 90723 Diphtheria, TT, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for IM use
      3. 90648 Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for IM use 
      4. 90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for IM use
      5. 90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for IM use
      6. Vaccine/Monoclonal Antibody Administration
        1. 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
        2. 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
        3. 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular = 1 unit
  4. 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:
      1. 99392 Periodic comprehensive preventive medicine reevaluation and management of an established patient; early childhood (age 1 through 4 years)
      2. 96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument
      3. 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for IM use = 2 units
      4. 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular = 2 units
  5. 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, Mother had additional questions that were answered by the RN. Mother agrees to proceed with the administration of nirsevimab.
    • CPT codes:
      1. 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for IM use
      2. 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
    • Coding Tip:
      1. 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, counseling does not equate to the management of a condition.

Payment Tips

Also consider the following payment tips: 

  1. Each practice should verify with third party payers if RSV monoclonal antibodies are a covered benefit and how they will be paid.
  2. As per the Affordable Care Act (ACA) payers have until 12 months after the new plan year following ACIP recommendations to recognize and pay for new vaccines. ACIP recommended nirsevimab on 8-3-2023. The AAP will be notifying the major national health plans about the recommendations and urge timely benefits coverage and appropriate payment for the vaccine and administration.
  3. Contracts should be reviewed regarding payment levels for nirsevimab. Include a provision in the contract for the health plan to not 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.  
Last Updated

09/07/2023

Source

American Academy of Pediatrics