MIR-2007-2B, February 2007

Zostavax ®

The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Medicare coverage. Medicare manual instructions [ Medicare Benefits Manual (Pub 100-02), Chapter 15, Section 50.4.4.2 – Immunizations] (see below) prohibit coverage unless the beneficiary is at risk directly related to exposure to a pathogen. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster. In an immunocompromised state, the vaccine is contraindicated and should not be administered. In 2007, the administration of this vaccination can be billed to the local carrier with the HCPCS code G0377 which is the equivalent of CPT 90471. Please note in Item 19 of the CMS-1500 claim or the electronic media claims (EMC) equivalent that you have administered Zostavax.

Medicare Benefits Manual (pub 100-02), Chapter 15 50.4.4.2 – Immunizations

(Rev. 1, 10-01-03) A3-3157.A, B3-2049.4, HO-230.4.C
Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule...In cases where a vaccination or inoculation is excluded from coverage, related charges are also not covered.

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.