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March 29, 2023

Reimbursement for Shingrix, the new zoster vaccine | 90750

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At the end of 2017, there was news that a new vaccine for shingles, Shingrix, was significantly more effective than the older vaccine, Zostavax.  The new vaccine was recommended in place of the old, and for patients who had already received the older vaccine.  An article in The New York Times summarized the benefits.

The CPT® code for Shingrix is 90750, and of course, there is only one ICD-10 code to remember for immunizations, Z23.  The patient needs two doses, separated by at least 2 months.

Coverage for shingles vaccine

Original Medicare doesn’t pay for this immunization under Part A or Part B.  That means, medical practice can’t give it to Medicare patients and be reimbursed for it.

The CMS website says

“Generally, Medicare prescription drug plans (Part D) cover all commercially-available vaccines.”

Patients with original Medicare will need to check their coverage and go to the pharmacy for the service. The cost to the patient will depend on the patient’s Part D coverage.  The Part D plan is not required to pay if in full, although the patient may receive a negotiated rate. For Medicare Advantage, check with your plan.

Commercial policies that are compliant with the Affordable Care Act (ACA) preventive coverage will pay for it, based on the recommendation of the Advisory Committee on Immunization Practices. (ACIP).

I checked a few websites, and it seems that Anthem, UnitedHealthcare, and Aetna are covering the vaccine.  It would be prudent to check for coverage before administering the vaccine, especially as patients purchase non-ACA plans.

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Last revised June 28, 2021 - Betsy Nicoletti
Tags: CPT codes for preventive services

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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