Coding & Payment For RSV Immunizations

Product Codes

Nirsevimab

Report codes 90380 or 90381 based on the dose administered: o.5 ml or 1.0 ml.

90380: Respiratory syncytial virus, monoclonal antibody, seasonal dose; o.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 season dose)

Clesrovimab

Report code 90382 Respiratory syncytial virus, monoclonal antibody, seasonal dose, 0.7 mL, for intramuscular use 

Administration Code

Per CPT guidelines, report the administration of nirsevimab and clesrovimab 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 RSV immunization administration. 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 RSV immunization, as these codes are limited to administering vaccine and toxoid products.

Vaccines for Children (VFC) Guidelines

To ensure appropriate payment when RSV  immunizations are 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 RSV immunizations are not reported with Z23 Encounter for immunization. Z23 is specific to immunization related to vaccines. While RSV immunizations are categorized as monoclonal antibodies by CPT, ICD10 CM's index guides us to code Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV).

Coding Vignettes

Newborn Hospital Admission
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 RSV immunization. The family's questions are answered and documented, and the newborn receives nirsevimab 0.5 ml before hospital discharge.

Coding Tip:
Inpatient counseling for RSV immunization 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 RSV immunization.

Outpatient Acute Illness Visit – First Season
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 vaccine, COVID-19 vaccines, and RSV immunization. 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.

90483 Immunization counseling by physician or other QHP when immunization(s) is not administered by provider on the same DOS; greater than 10 minutes up to 20 minutes 

Coding Tip:
Modifier 25 is required on 99213 to report codes 99213 and 90483 together.

Preventive Visit and Routine Immunizations – First Season
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 on immunizations and will receive the recommended 2-month vaccines. In addition, the provider counsels the mother about RSV immunization. All of the mother's questions were answered, and she would like to proceed with the recommended immunizations, including clesrovimab.

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

90382 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.7 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.

RSV Immunization Visit (Clesrovimab)
A 7-month-old established patient presents for a scheduled RSV immunization injection during RSV season. 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 clesrovimab.

CPT codes:
90382 Respiratory syncytial virus, monoclonal antibody, seasonal dose, 0.7 ml, for intramuscular use

96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection= 1 unit

Coding Tip:
Additional counseling provided by the RN and subsequent administration of RSV immunization do 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 constitute 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 RSV Immunizations. 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 payment for the immunization product and related expenses, ensure payment is made for administration, which is a separate expense.

We encourage you to contact your payers and obtain their payment policies for reporting RSV immunizations, as well as your contract details for payment of immunizations, in writing.

AAP Payment Advocacy for RSV Immunization

To ensure all infants are protected against severe RSV illness, the AAP is urging commercial and public insurers to appropriately pay for RSV immunizations and to reduce administrative burden for practices related to prior authorization.

To assist in our advocacy efforts, please report to us any denial trends via the coding and payment hotline, include the payer’s policy for RSV immunizations and electronic remittances to review. All patient information must be fully 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 1996. 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

AAP Immunization Coding Table
AAP Vaccine Financing and Coding 
AAP Standalone Immunization Counseling Factsheet

Visit our Child Health Finance and Payment Strategy page for resources related to coding and payment.