For example, providers use CPT 78264 to bill the stomach imaging only when the procedure lasts 4 hours or less. On the other hand, they use CPT code 78265 for imaging the stomach and small bowel, and the procedure lasts for 24 hours to 26 hours. In addition, the use of CPT 78265 involves imaging of both the stomach and small intestine to monitor the passage of food. Furthermore, providers use a different code (CPT 78266) to bill for imaging the small bowel and colon transit, where the procedure lasts for 24 to 26 hours.

For more detail and information about CPT codes for gastric studies and treatments, let’s discuss what a gastric emptying study is.

What is a Gastric Emptying Study?

Gastric emptying study is the process of tracking gastric motility. The study tracks how long food (meal or drink) takes to move through a patient’s stomach and excrete or empty from it. This passage of food and liquid through the stomach is also called gastric motility.

Healthcare providers test patients’ gastric motility to determine whether it works normally. The procedure assesses the conditions that can affect the process of food when it leaves the stomach and enters the small intestine. If the coordinated passage of food is faster or slower than usual, the patient has a medical condition and needs medical treatment.

The method usually applied for testing gastric mobility is gastric emptying scintigraphy (GES). GES is a type of medicine imaging test that generates images by scanning radiation in patients’ bodies. For better results, patients must ingest a meal with a radioactive tracer in it to make their stomach show up in the scan. This is what healthcare practitioners mean when they suggest patients undergo a gastric emptying imaging study.

Another method of gastric emptying scan is Gastric Emptying Breath Test (GEBT). Physicians can track the progress of a meal through a patient’s digestive system by measuring gases in a breath. To undergo the test, a patient must consume a special meal containing a carbon molecule (carbon-13), producing a specific and measurable form of carbon dioxide (CO2-13).

CPT Codes for Gastric Emptying Study

The CPT codes for gastric emptying imaging study are:

CPT 78264

CPT code 78264 refers to a gastric emptying imaging study, a procedure used to calculate the rate at which the stomach empties. This imaging study involves using a radiopharmaceutical or tracer to obtain real-time images of the stomach’s functionality. The procedure is particularly useful for diagnosing conditions like gastroparesis, where the stomach empties its content too slowly, or dumping syndrome, where it empties food too quickly.

CPT 78265

Providers use CPT code 78265 for a gastric emptying imaging study that includes the assessment of small bowel transit. This CPT code represents a more comprehensive assessment compared to CPT 78264 because it involves not only tracking how quickly the stomach leaves food, but also how the small intestine processes the ingested meal.

CPT 78266

CPT code 78266 refers to a more comprehensive gastric emptying imaging study. This procedure assesses the transit time of food through the stomach, small bowel, and colon over multiple days. It involves the ingestion of a meal containing a tracer, with continuous imaging to evaluate the functioning of the digestive muscles.

Do CPT 78264 and 78265 Codes Need a Modifier?

Healthcare providers must understand the context of services provided when adding modifiers to CPT codes 78264 and 78265 after performing a gastric emptying imaging study. Here is a list of appropriate modifiers.

Modifier 26 (Professional Component)

The Modifier 26 is used with code 78264-65 when practitioners bill for services that include a professional component. Adding modifier 26 indicates that the provider is billing for the interpretation of the imaging study. However, when healthcare providers use equipment, they use modifier TC to bill the procedure.

For example ➜ A patient undergoes a gastric emptying study, and the same healthcare provider performs the imaging (technical component) and the image interpretation (professional component). According to old billing practices, modifier 29 would indicate that both aspects are being billed together. However, in practice, providers typically wouldn’t use modifier 29. Instead, separate billing for the professional (26) and technical components (TC) might be more appropriate based on modern billing practices.

Modifier 59 (Distinct Procedural Service)

Healthcare providers add modifier 59 when the procedure is different or independent from other treatment services performed on the same day. The use of a modifier indicates that the service is not part of the bundled procedure.

For example ➜ A patient visits the hospital for a gastric emptying study due to delayed gastric emptying symptoms. During the same visit, the physician performs a hepatobiliary scan to check for any additional issues affecting the patient’s biliary system. To indicate that these two procedures are distinct from each other, the codes are:

● CPT Code 78264 – (Gastric emptying study)
● Modifier 59 – (Distinct procedural service)
● CPT Code 78227 – (Hepatobiliary scan

Modifier 76 (Repeated Procedure by Same Physician on The Same Day)

If the gastric emptying imaging study needs to be repeated on the same day by the same physician, this modifier would be used to indicate the repeated service. Healthcare providers should use modifier 76 with codes CPT 78264 and 78265 if the same physician needs to repeat the gastric emptying imaging study on the same day.

For example ➜ A patient visits the hospital for a gastric emptying study to diagnose a motility disorder. After receiving immediate treatment, the same physician conducts another gastric emptying study later in the day to confirm the effectiveness of the treatment.

Modifier 77 (Repeated Procedure on The Same Day by Different Physician)

Adding modifier 77 to CPT 78264 indicates the administration of the same service or procedure on the same day by a different physician or healthcare professional. When a patient needs to undergo the gastric imaging study again on the same day, but due to the unavailability of the same physician, providers assign another doctor to perform the task and add a modifier to bill the process.

For example ➜ A patient undergoes a gastric emptying study by Dr. AAA in the morning. Later in the day, Dr. BBB repeats the procedure to verify the results. Because a different physician is performing the repeat procedure, so modifier 77 is added.

Modifier 91 (Repeated Clinical Diagnostic Laboratory Test)

Healthcare providers add modifier 91 to the existing CPT codes, typically for laboratory tests if the imaging study is repeated for clinical reasons. The modifier indicates the necessity of repeated procedures to get accurate results.

For example ➜ A patient undergoes an initial gastric emptying study early in the morning. Due to the patient’s symptoms and to gauge the impact of different meals, the physician orders repeat gastric emptying studies after lunch and dinner.

Modifier 52 (Reduced Services)

Providers use the modifier if the gastric emptying study is reduced or discontinued with the physician’s consent. Modifier 52 is used to show that the service provided was less than usually required. It indicates partial reduction or elimination of procedures and services. The modifier 52 provides a reason to insurance providers for billing reduced services.

For example ➜ A patient visits a hospital for a gastric emptying study. The physician determines that a shorter duration of monitoring is sufficient for this patient’s diagnostic needs. As a result, the study is partially reduced, and the physician bills for the reduced procedure using modifier 52.

Modifier 53 (Discontinued Procedure)

Modifier 53 is applied to bill the incomplete procedure if the gastric emptying study is started but discontinued due to extenuating circumstances that threaten the patient’s health and well-being.

For example ➜ A patient undergoing a gastric emptying study starts experiencing severe adverse reactions, such as sharp abdominal pain or vomiting. The physician decides to discontinue the study to ensure the patient’s safety.

Reimbursement for Gastric Emptying Study Services

Medicare reimburses CPT codes 78264, 78265, and 78266. The Physician Fee Schedule provides practices with a standard payment structure for covered services, including gastric emptying studies represented by codes CPT 78264, 78265, and 78266.

Moreover, these reimbursement rates vary depending on various factors, such as the geographical location where practices operate and the policies of the local Medicare Administrator Contractor (MAC).

Therefore, before providing gastric emptying study services to Medicare-covered patients, providers must consult the Physician Fee Schedule and MAC to get full reimbursement for their services.

FAQs

What is the difference between CPT code 78264 and 78265?

CPT code 78264 is used for imaging studies that assess the emptying of the stomach only. The procedure typically lasts 4 hours or less. The study, which uses CPT code 78265, involves assessing the stomach and small bowel transit to monitor the passage of food through the digestive system. The procedure typically lasts 24 to 26 hours.

Who needs a gastric emptying test?

Patients may need this test if they have symptoms of gastroparesis, which include:

• Abdominal (belly) pain
• Bloating
• Nausea and vomiting
• A feeling of fullness after just a few bites of food
• Loss of appetite
• Weight loss

This BellMedEx guide covers the most common CPT codes for administering RSV vaccine for adults, children, and pregnant patients. But let’s dive in the basics first.

What Are CPT Codes?

Current Procedural Terminology (CPT) codes are procedure codes to identify diagnostic, medical, and surgical procedures and services. These codes act as a universal language in healthcare. And they are created and maintained by The CPT® Editorial Panel, authorized by the AMA Board of Trustees.

The CPT codes also identify the diagnosis and administration of RSV vaccine under public and private health insurance programs. These codes also help optimize medical billing processes, including claim submission and more.

The Most Common CPT Codes for RSV Vaccine

All these CPT codes are somehow related to diagnosing and treating diseases caused by respiratory syncytial virus (RSV), including the vaccine administration and the provider’s counseling.

• 96380
• 96381
• 90380
• 90381
• 90678
• 90679
• 90683
• 90471

Let’s dive into the details of these CPT codes now.

96380

96380 is used for the administration of a monoclonal antibody for respiratory syncytial virus (RSV) by intramuscular injection. It’s appended when a physician or another qualified healthcare professional also provided counseling related to the administration. This code showcases the seasonal dose of the monoclonal antibody and includes the additional step of providing counseling to the patient.

For example, take a scenario where a pediatrician sees a 6-month-old patient weighing 4.8 kg for an RSV prophylaxis visit. During this visit, the physician administers a 0.5 mL dose of nirsevimab (sold under the brand name “Beyfortus”) and provides detailed information on RSV, its prevention, and the importance.

The physician uses code 96380 to document both the administration of the monoclonal antibody and the counseling provided. When billing, append this CPT code for RSV vaccine (96380) with any relevant modifiers and the appropriate diagnosis code, Z29.11, to indicate prophylactic immunotherapy for RSV.

96381

CPT code 96381 is appended for the administration of a monoclonal antibody for RSV by intramuscular injection without the requirement for counseling at the time. Remember this code applies to the seasonal dose of the monoclonal antibody when the counseling was not part of the visit or occurred at a different time.

For example, if a 7-month-old patient receives a 1 mL dose of nirsevimab, the RSV vaccine, during a follow-up visit after the initial counseling provided two weeks earlier, the healthcare provider would use code 96381 to capture the administration of the monoclonal antibody.

Note that this code is used for documenting the administration event only. And the counseling is billed separately if applicable. The appropriate DX code, Z29.11, should also be reported alongside this administration code.

90380

CPT code 90380 represents the RSV monoclonal antibody product for a 0.5 mL seasonal dose intended for intramuscular use. This CPT code for RSV vaccine is specific to the product’s dosage and is used to report the administration of this quantity of the monoclonal antibody.

For example, when a 3-month-old infant weighing less than 5 kg is administered a 0.5 mL dose of nirsevimab during an RSV prophylaxis appointment, the healthcare provider would use code 90380 to bill for this specific dosage. Combine this CPT code for RSV vaccine dosage with the diagnosis code Z29.11.

90381

CPT code 90381 is used for the administration of a 1 mL dose of the RSV vaccine for intramuscular use. Append this code when giving the mentioned dose to the well-child patients, typically those weighing 5 kg or more.

For example, if a 6-month-old child patient weighing 6 kg receives a 1 mL dose of nirsevimab during their RSV prophylaxis visit, use code 90381 to indicate the administration of this dosage (1mL). Report this code along with the appropriate administration code (96380 or 96381) and the DX code, Z29.11.

90678

CPT code 90678 reports the bivalent RSV vaccine, preF, subunit, for intramuscular use. This RSV vaccine is recommended for adults aged 60 years and older, as well as pregnant patients between 32 and 36 weeks of gestation. It helps reduce the incidence and severity of RSV in older adults and pregnant women.

Append 90678 with the DX code (Z23) to reflect the patient’s need for the vaccine and the administration code 90471 to indicate the immunization service provided.

And if the payer requires, append modifier 33 to indicate the preventive service, which is exempt from cost-sharing. You can check with your most common payers to confirm if the modifier 33 is required.

90679

The CPT code for RSV vaccine Arexvy recombinant, subunit, adjuvanted, is 90679 for intramuscular use. This RSV vaccine is recommended for adults aged 60 years and older. For example, the provider would use this code if an elderly patient receives the recombinant RSV vaccine during a scheduled vaccination appointment.

Report 90679 with the administration code 90471, and the appropriate DX code to justify the vaccine administration.

90683

90683 is designated for the RSV vaccine Mresvia, mRNA lipid nanoparticles, for intramuscular use. This mRNA-based vaccine is recommended also for adults aged 60 years and older. For example, the provider would append the code 90683 with the administration code 90471 to reflect the scope of immunization. Again, include the relevant DX code that supports the patient’s eligibility for the vaccine.

90471

90471 is used for the administration of a single vaccine or combination vaccine/toxoid, including those administered intramuscularly. This CPT code covers the service of administering a vaccine and includes any related counseling and documentation.

Here’s the detailed summary of the code:

CPT code 90471, “Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)”.

This CPT code is relevant for reporting the administration of RSV vaccines, such as the bivalent subunit vaccine (CPT code 90678) designed for adults 60 years and older and pregnant patients at 32-36 weeks gestation.

For example, if an adult patient receives the RSV vaccine during a routine office visit, the provider would use code 90471 to bill for the administration of this vaccine. They would also use the administration code and the diagnosis code Z23 (“Encounter for immunization”) to showcase the vaccine administration was for immunization purposes.

And suppose if the vaccine administration is part of a preventive service, append the modifier 33 to indicate that the service is not subject to patient cost-sharing.

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.

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.