As healthcare providers, we frequently see patients concerned about shingles. Shingles is an unpleasant condition caused by the varicella-zoster virus, the same virus that causes chickenpox. While anyone can get shingles, the risk increases with age. Shingles appears as a painful rash and blistering skin condition that can last for weeks.
For patients concerned about shingles risk and costs, a shingles vaccine can provide much-needed peace of mind. However, the variety of vaccine options and insurance considerations can also be a source of confusion. As physicians, we need to have a firm grasp of the CPT codes associated with shingles immunizations to provide the best care for our patients while also sustaining our practice.
This blog will break down the CPT coding for shingles vaccines and how they enable us to make these vital preventatives accessible and affordable.
What is meant by CPT Codes?
CPT codes for shingles vaccine are special medical codes used to identify and bill the shingles vaccinations. Shingles vaccines like Shingrix and Zostavax have dedicated CPT codes to enable proper medical billing. Healthcare providers use these standardized CPT codes to communicate with insurance companies when a shingles vaccination is administered.
For example, 90736 represents the Zostavax injection for shingles. And 90734 is the code for a Shingrix shot.
By including these codes on claim forms, doctors tell the insurance company exactly which vaccine was given. This allows insurers to understand what service was rendered and reimburse the provider appropriately.
So CPT codes eliminate confusion and enable transparent billing for shingles vaccinations. They act as unique identifiers to help the medical billing process run smoothly.
Here’s a table providing prescribing information for the Shingrix and Zostavax vaccines, along with the required CPT codes for further clarification.
| Vaccine | Shingrix | Zostavax |
| Dosage Schedule | 2 doses (2nd dose 2-6 months later after Ist one) | Only one dose |
| Vaccine Description | Recombinant, adjuvanted | Live-attenuated |
| Age recommendation by FDA | Adults with 50 yr and older even though previously vaccinated with Zostavax | Adults with 50 years and older |
| Overall effectiveness by 3 years | 91% | 51% |
| Administration Site | Intramuscular | Subcutaneous |
| CPT Code ® | 90750 for Zoster(shingles) , (HZV) | 90736 for Zoster(shingles) vaccine (HZV), live attenuated |
How are CPT Codes used for the Shingles Vaccine?
As you are aware, CPT codes are the professional language used between healthcare and insurance providers for billing shingles vaccine. Get an insight into how these CPT codes are used for shingles vaccine:
Help with the identification of vaccine type
The CPT codes 90750 and 90736 specifically identify the shingles vaccine, providing information to insurance payers and medical records about the administered vaccine type.
Help with the reimbursement process
For reimbursement purposes, healthcare providers use CPT codes to administer the shingles vaccine. Healthcare providers use either the CPT code 90750 or the CPT code 90736, and insurance providers are responsible for determining the appropriate reimbursement.
Help track the correct CPT code usage
Healthcare providers use CPT codes to track the number of shingles vaccines administered. This tracking can help determine vaccine coverage and identify disease outbreaks. Accurate Patient Health Information (PHI) along with the CPT code ensures precise documentation of shingles vaccines.
Common CPT Codes used for Shingles Vaccine
When it comes to accurate billing for the shingles vaccine, two CPT codes take center stage: 90736 and 90750. These codes provide clarity for providers and payers alike, helping ensure proper reimbursement for this vital vaccine.
CPT Code 90750
CPT code 90750 is specific to the administration of Shingrix, the shingles vaccine. This vaccine helps prevent the painful rash and blisters caused by the varicella-zoster virus – the same virus that causes chickenpox. Here’s what you need to know about 90750:
- It covers both the cost of the vaccine and the healthcare provider’s administration fee. Each dose given is reported separately.
- The code is used exclusively for Shingrix. Other shingles vaccines like Zostavax use different codes.
- No modifier is required. However, one can be appended to convey additional details about the patient or vaccination site.
- The ICD-10 diagnosis code Z23 (encounter for immunization) is commonly used with 90750 to indicate the vaccine’s intent.
- Shingrix is given in a 2-dose series, with the second dose administered 2-6 months after the first. Each dose is reported separately with 90750.
- The vaccine contains a recombinant varicella-zoster virus antigen and an adjuvant to boost immune response. This “subunit” design prompts immunity without exposing patients to live virus.
- Shingrix is over 90% effective at preventing shingles and long-term nerve pain in patients 50 years and older.
CPT Code 90736
CPT code 90736 is used to report the administration of the zoster (shingles) vaccine, Zostavax. This live attenuated vaccine helps protect patients from developing shingles, a painful rash caused by the varicella-zoster virus (VZV). Here’s what you need to know about 90736:
- 90736 covers one dose of the zoster vaccine, including both the vaccine product itself and its administration by a healthcare professional.
- It is important to report 90736 separately from any other services the patient receives during the same encounter, such as an office visit or additional vaccinations. This ensures proper reimbursement.
- Do not confuse Zostavax (90736) with Shingrix (90750), the newer recombinant zoster vaccine. These are two different products with separate codes.
- Modifiers may be appended to 90736 to convey additional information, such as the location where the vaccine was administered (e.g. physician’s office). However, modifiers are not required.
- Make sure to verify patient eligibility and any applicable age, frequency, or other guidelines before administering Zostavax and reporting 90736. Proper coding is key for appropriate payment.
Correct and Incorrect Usage of CPT codes for Shingles Vaccine
If you use the incorrect CPT code for the shingles vaccine, it can lead to claim denials, surprise medical bills that hurt patients, and audits and reimbursement impacts for healthcare practices. Therefore, always ensure that you are using the correct CPT code.
Case #1 – Reporting Vaccine Units
❌ Incorrect: Your medical coder can report multiple units of vaccine used, instead of a single dose of Shingrix, which should be administered to patients.
✔️ Correct: You are required to report the administration of a single unit of the Shingrix vaccine.
Case #2 – Using CPT Code 90750 for Zostavax
❌ Incorrect: You may confuse the two codes for shingles, 90750 and 90736. For instance, you might mistakenly use 90750 code for Zostavax instead of Shingrix.
✔️ Correct: Always consult a codebook to ensure the correct code is used for the relevant vaccine.
Case #3 – Bundling with Other Services
❌ Incorrect: Bundling the Shingrix vaccine with other services, such as additional vaccinations or office visits, may result in improper reimbursement.
✔️ Correct: CPT code 90750 should be billed separately from other services to ensure proper reimbursement.
Applying Modifiers to the Shingles Vaccine CPT Codes
There are some cases when you can use POS modifiers. This is if the shingles vaccine is administered in any other location other than physician office. Here are some examples :
- 20 = Urgent Care Facility
- 21 = Inpatient Hospital
- 22 = Outpatient Hospital
If patient takes the shingles vaccine in outpatient hospital setting, the correct code used for this vaccine can be: [90736-13]
Conclusion
For accurate medical billing and healthcare revenue cycle management the usage of correct CPT code is important. The two main codes 90750 and 90736 are used for reporting shingles vaccines.
