Nirsevimab Coding & Payment

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.

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

CPT codes 90380–90381 were approved by the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Editorial Panel in May 2023 and 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

CPT released 2 new codes specific for reporting the administration and counseling of nirsevimab effective 10/06/2023. 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 90461–90462 or 90471– 90472 for the administration of nirsevimab, as these codes are limited to administering vaccine and toxoid products.

The AAP is working with payers to update their payment systems and payment guidance. We encourage you to contact your payers and get their guidance on reporting nirsevimab in writing and report any discrepancies in CPT guidelines that appear in their guidance to the coding hotline with an attachment of the documented guidance. Using the appropriate diagnosis CPT code is important for billing, claims payment, data collection, and quality metrics.

To prevent cost share from being passed on to the patient, append modifier 33 to the administration code. This indicates to the payer that this was part of a preventive service.

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 important for billing, claims payment, data collection, and quality metrics.

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. All of the family's questions are answered and documented, and the newborn receives nirsevimab 0.5 mL prior to hospital discharge.

Coding Tip:
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.
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 would like to know what else she could do to protect her baby from 2. 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 we will discuss more when the baby returns next week for a well-child check.

CPT codes:
99213 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.

Preventive medicine counseling codes are not reportable with well visit codes 99381-99385 and 99391-99395
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 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

96380-33 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 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

96380-33 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

96381-33 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, counseling does not equate to the management of a condition.

Payment Tips

Consider the following payment tips:

The Centers for Medicare & Medicaid Services (CMS) accepted the recommendation from the AAP to set the interim work relative value units (RVUs) for the administration of nirsevimab similar to that of existing vaccine administration codes 90460 and 90471.

CPT Code Work RVU Total RVU

96380 0.24 0.67

96381 0.17 0.6
Payment policies vary by payer and your contract with them. Contracts 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 coding guidance on reporting nirsevimab in writing as well as your contract details for payment of immunizations.

Visit our practice management page for resources related to contracting and payment.

To assist in our advocacy efforts please report to us any discrepancies in CPT guidelines that appear in their guidance, as well as 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 HIPPA-covered entity.
Payers must comply with the ICD-10-CM and CPT coding conventions and guidelines as part of the HIPPA 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.
On 10/27/23 the AAP has submitted advocacy letters to payers supporting coverage and payment of both the nirsevimab product codes and the newly effective administration codes.
The Centers for Medicare & Medicaid Services (CMS) accepted the recommendation from the AAP to set the established payment rates similar to other pediatric immunization administration services
It is imperative to check the AMA CPT public website throughout the year to obtain the necessary updates to the CPT code set.