Shingles Vaccine CPT Code: Accurate Billing and Reimbursement Insights for 2025

The shingles vaccination is recommended for individuals aged 50 and older, as the CDC estimates that one in every three persons in the United States may acquire shingles throughout their lifetime. The CDC also says that Shingrix, the favored vaccination, is more than 90% effective in preventing shingles and postherpetic neuralgia, as opposed to the earlier Zostavax vaccine, which has an effectiveness rate of around 51%. As the demand for shingles vaccine grows, healthcare providers must charge properly using the relevant CPT code to minimize claim rejections, guarantee prompt reimbursement, and maintain compliance.

Inaccurate or incorrect coding for the shingles vaccination can result in severe administrative costs, such as claim delays, rejections, and possible compliance breaches. According to current data from the American Medical Association (AMA), erroneous coding is one of the top causes of billing errors in the United States’ healthcare system, accounting for billions of dollars in lost revenue annually.

This blog will provide a clear analysis of the exact CPT codes for both Shingrix (CPT 90750) and Zostavax (CPT 90736), as well as advise on billing best practices and Medicare and commercial insurance coverage policies to ensure that your practice.

Shingrix Vaccine – CPT Code 90750

Shingrix is currently the only shingles vaccine used in the United States, making CPT 90750 critical for proper reporting and payment. This section concisely overviews the vaccine’s clinical profile, billing method, and Medicare-specific coverage guidelines.

Vaccine Overview

Shingrix is a recombinant zoster vaccine that is adjuvanted and delivered intramuscularly.

It is recommended for those above fifty years and those 18 and older with immunocompromised conditions.

The CDC advises a two-dose regimen administered two to six months apart.

According to CDC-referenced scientific research, the efficacy in preventing shingles and postherpetic neuralgia approaches 90%.

Billing and Coding

CPT 90750 only applies to the Shingrix medicine, not its administration.

Use 90471 for the first vaccination delivered during a visit, and 90472 for any subsequent vaccines provided.

Use ICD-10-CM code Z23 on claims to indicate the interaction is for vaccination.

Add the NDC (e.g., 58160-823-11) to meet payer requirements.

If the patient delivers the vaccination (e.g., through a pharmacy), utilize modifier FB with 90750 and a $0 product fee, but bill the administration.

Medicare Coverage

Shingrix is not covered by Medicare Part B. This is a common cause of misunderstanding.

It is covered by Medicare Part D, which administers prescription medication benefits.

According to the Inflation Reduction Act amendments, people with Part D coverage will normally have no out-of-pocket expenses by January 1, 2023.

Shingrix cannot be directly billed by providers under Part B.

Zostavax – CPT Code 90736

Zostavax, the first shingles vaccine, has been removed from the United States since November 2020. This section discusses historical coding and how to handle previous claims or documents concerning CPT 90736.

Vaccine Overview

Zostavax was a live, attenuated zoster vaccination authorized for adults 60 and over.

Merck ceased Zostavax production and distribution in November 2020.

It was a single-dose immunization given subcutaneously.

Its efficacy was lower than Shingrix, particularly in those over 70.

Billing and Coding

CPT 90736 refers to the Zostavax medication, not its administration.

The administration was billed separately as 90471.

Use ICD-10-CM code Z23 for vaccinations.

Claims for CPT 90736 made after November 2020 are likely to be refused owing to discontinuance and product unavailability.

When resubmitting or reviewing previous claims, always verify the dates of service and make sure they precede the cessation.

Medicare Coverage

Zostavax was covered by Medicare Part D and not Part B.

Before its demise, billing would have gone through the Part D prescription medication coverage.

Unless insured by Low-Income Subsidy (LIS) schemes, patients were normally responsible for contributing costs.

No new claims should be filed under CPT 90736. Use exclusively to document or correct past claim data.

Billing Best Practices For Shingles Vaccine CPT Code

Shingles Vaccine CPT Code billing must be accurate to minimize denials and ensure compliance. This section identifies crucial areas where physicians and billing professionals must pay attention.

Accurate Code Selection

Choosing the right code begins with determining which vaccination was provided.

For Shingrix, the recombinant zoster vaccination, use CPT 90750.

For Zostavax, the live attenuated vaccination, use CPT 90736.

Pair the vaccination code with the appropriate administration code—usually 90471 for the first injection and 90472 for further doses during the visit.

Documentation

To be successful, billing documentation must be thorough and correct. The patient’s record has to include the vaccine name, lot number, expiration date, method and site of administration, and a statement verifying patient consent. The specific ICD-10 diagnosis code for immunization, Z23, must also be included on the claim. To satisfy payer reporting requirements, provide the National Drug Code (NDC) for every vaccine product. Lack of important details frequently leads to denials or medical record requests, dragging out the reimbursement process and adding an administrative burden.

Modifier Usage

Modifiers can explain services that might otherwise be refused.

Modifier 25 should be used when performing a different E/M service during the same visit.

Use Modifier 59 if a separate procedural service is invoiced in addition to the vaccination.

Place of Service (POS) designations such as 11 (office), 20 (urgent care), and 22 (outpatient hospital) should correspond to the service location.

Conclusion

Accurate coding, correct documentation, and proper modifier usage are critical to effective billing for the shingles vaccination. Each claim must include the correct CPT code for the administered product and adhere to payer-specific regulations. Missing or erroneous facts, such as the lot number, NDC, or patient permission, might lead to rejections or delays. Including the ICD-10 code Z23 is crucial for indicating a vaccination encounter. Submitting claims without the proper data increases administrative burden and hinders reimbursement. Adherence to these billing rules promotes clean claims, prompt payments, and continuous compliance.