Shingles, a painful viral infection, can be prevented through vaccination. Healthcare providers must understand the correct CPT (Current Procedural Terminology) codes for shingles vaccines like Shingrix and Zostavax to ensure proper billing and reimbursement. This article will guide into the significance of shingles vaccine CPT codes, how to use them correctly, and the importance of accuracy in billing.
What Are CPT Codes?
CPT codes are a set of medical codes used to describe specific medical services and procedures. These codes are essential for medical billing, as they streamline the process of reimbursement from insurance companies, government programs, and other healthcare payers. In simple terms, CPT codes help healthcare providers get paid for their services.
There are three categories of CPT codes:
- Category I: The most commonly used codes, such as those for vaccinations, diagnostics, and surgeries.
- Category II: Codes for performance measurement, which are optional but can help track healthcare quality.
- Category III: Temporary codes for emerging technologies and services that are not yet widely recognized.
Each CPT code is a unique identifier for a specific medical procedure, ensuring that all healthcare services are standardized and billed accurately.
Shingles Vaccine: Overview
Shingles is a reactivation of the varicella-zoster virus, which causes chickenpox. As we age, the immune system weakens, making older adults more susceptible to developing shingles. The CDC recommends the shingles vaccine for adults 50 years and older, as it significantly reduces the risk of developing the infection.
There are two vaccines for preventing shingles:
- Shingrix (90736): The preferred vaccine for adults aged 50 and older. Shingrix is administered in two doses, and studies have shown it to be more than 90% effective in preventing shingles and postherpetic neuralgia, a common complication.
- Zostavax (90732): An older vaccine, recommended for adults aged 60 and older. It is less effective than Shingrix and has been largely replaced by the newer vaccine.
Shingrix vs. Zostavax
| Vaccine | Recommended Age | Dosage | Effectiveness |
|---|---|---|---|
| Shingrix (90736) | 50+ | Two doses, 2-6 months apart | 90%+ effective |
| Zostavax (90732) | 60+ | One dose | 51% effective |
Shingrix is preferred due to its higher effectiveness, especially in older adults who are at higher risk of severe shingles complications.
Shingles Vaccine CPT Codes
There are two primary CPT codes used for billing the shingles vaccine:
90736 – Shingrix Vaccine
- When to Use: This code is used for the Shingrix vaccine, which is recommended for adults aged 50 and older. It is administered in two doses, typically spaced 2 to 6 months apart.
- Billing Considerations: Ensure that the vaccine is administered according to the CDC’s guidelines for age and dosage. Incorrect usage can result in insurance claim denials or delays in reimbursement.
90732 – Zostavax Vaccine
- When to Use: This code is used for the Zostavax vaccine, which is recommended for adults 60 and older. It is administered as a single dose.
- Billing Considerations: Zostavax is less commonly used today due to the preference for Shingrix, but it’s still important for billing purposes if the patient chooses this older vaccine.
Example Billing Scenario
A 60-year-old patient visits a healthcare provider for a shingles vaccination. The provider administers the Shingrix vaccine, which is billed using CPT code 90736. If the provider mistakenly bills 90732 (Zostavax), the insurance may not approve the claim, as the vaccine is not recommended for this patient.
CPT Code 90750
CPT code 90750 is used for billing the administration of the recombinant zoster vaccine (Shingrix). This vaccine is designed to protect against shingles (herpes zoster) and its complications.
When to Use:
- For patients aged 50 and older, per CDC guidelines.
- It covers each dose of the two-dose series for Shingrix.
Billing Guidelines:
- Ensure the patient’s age matches the recommended guidelines (50+ years).
- Use this code specifically for Shingrix, as it is distinct from the older Zostavax vaccine.
- Pair the code with an appropriate ICD-10 code, such as Z23 (encounter for immunization).
Example Usage:
- A patient aged 55 receives their first dose of Shingrix. The CPT code 90750 is used for billing the vaccine administration.
CPT Code 90736
CPT code 90736 refers to the Zoster (shingles) vaccine live (Zostavax), a single-dose vaccine designed to prevent shingles in adults.
When to Use:
- For patients aged 60 and older, per CDC guidelines.
- It applies to the administration of the Zostavax vaccine only.
Billing Guidelines:
- Verify the patient’s age (60+ years) to meet the recommended usage criteria.
- Use this code exclusively for Zostavax and not for Shingrix.
- Pair the code with a suitable ICD-10 code, such as B02.9 (shingles without complications) or Z23 (immunization encounter).
Example Usage:
- A patient aged 65 receives the Zostavax vaccine during a routine healthcare visit. CPT code 90736 is used to bill for the vaccine.
Key Difference:
While 90750 is for Shingrix, suitable for those aged 50 and above, 90736 is for Zostavax and targets patients aged 60 and older. Always confirm the correct vaccine and patient eligibility before coding.
Why Accurate CPT Coding Matters for the Shingles Vaccine
Correct CPT coding is essential for ensuring that healthcare providers receive appropriate reimbursement for services rendered. When it comes to shingles vaccines, inaccurate coding can lead to claim rejections, delays in payments, or even financial losses. Providers should ensure they use the correct vaccine code for the patient’s age and vaccine choice.
For example, if a 50-year-old patient receives Zostavax but is billed using the Shingrix CPT code 90736, the insurance company might deny the claim, as Zostavax is only recommended for patients over 60. This mistake can cause confusion, delays, and extra administrative work to resolve the issue.
Additionally, using the wrong CPT code may result in patients being charged incorrectly, leading to dissatisfaction and potential disputes.
Tips for Avoiding Billing Errors
- Double-check the patient’s age and vaccine eligibility before administering the vaccine.
- Use electronic billing systems to cross-check vaccine codes and ensure accuracy.
- Stay updated on the latest vaccine guidelines from the CDC to ensure the correct CPT codes are applied.
Updates to Shingles Vaccine CPT Codes
As of 2024, there have been no significant changes to the CPT codes for shingles vaccines. However, it’s important for healthcare providers to stay informed about any future updates to ensure they continue to bill correctly. The AMA periodically releases updates to the CPT codes, and the CDC regularly issues new vaccination guidelines.
Healthcare providers can subscribe to official newsletters from the AMA, CMS, or the CDC to stay informed about any potential code changes.
Conclusion
Proper understanding and usage of shingles vaccine CPT codes 90736 for Shingrix and 90732 for Zostavax are crucial for accurate billing and reimbursement. Healthcare providers must stay up to date with vaccine recommendations and coding guidelines to ensure they are correctly billing for services and minimizing any financial impact on their practice.
FAQ‘S
What are the CPT codes for Shingrix and Zostavax?
90736 is the CPT code for Shingrix, and 90732 is the CPT code for Zostavax.
Why is it important to use the correct CPT code for shingles vaccination?
Using the correct CPT code ensures accurate billing and reimbursement and prevents insurance denials.
What happens if I use the wrong CPT code for the shingles vaccine?
Incorrect CPT coding can lead to claim denials, delayed payments, and incorrect charges for patients.
Can I bill for the shingles vaccine administration separately?
Yes, the administration of the vaccine may have a separate CPT code for billing, but it depends on the insurance guidelines.
How often do shingles vaccine CPT codes change?
CPT codes for vaccines generally change infrequently, but providers should stay updated on any changes released by the AMA or CDC.
Do I need to use an ICD-10 code alongside the CPT code for shingles vaccination?
Yes, a proper ICD-10 diagnosis code should accompany the CPT code for shingles vaccination to ensure complete and accurate billing.
