If you work in a pharmacy, a primary care clinic, or a public health department, you have probably heard the buzz. Respiratory Syncytial Virus (RSV) is no longer just a concern for infants. Since 2023, adults aged 60 and older have a powerful new defense: Arexvy, the first RSV vaccine approved by the FDA for older adults.
But having the vaccine is one thing. Getting paid for administering it is another.
You need the right codes. Specifically, you need the correct Arexvy CPT code to ensure your claims don’t get rejected. With the arrival of new vaccines (including Pfizer’s Abrysvo), the billing landscape has shifted.
In this guide, we will walk you through everything you need to know. We will cover the specific product code, the administration codes, how to bill Medicare, and common mistakes that delay payment.
Let’s get your claims paid correctly.
What is Arexvy? A Quick Overview
Before we dive into the numbers, let’s ensure we are all talking about the same shot. Arexvy (pronounced ah-REX-vee) is manufactured by GSK. It is an adjuvanted vaccine designed to boost the immune response against RSV.
Who is eligible?
- Adults aged 60 years and older.
- It is a single-dose vaccine (for now).
- It is given via intramuscular injection, usually in the deltoid muscle.
Because this is a brand-new vaccine category, payers have been scrambling to update their systems. This makes having the precise Arexvy CPT code critical. If you use a generic “vaccine administration” code from 2020, you will likely see a denial.
The Specific Arexvy CPT Code: Product vs. Administration
One of the biggest sources of confusion is the difference between the product code (the actual liquid in the vial) and the administration code (the act of giving the shot).
You must bill two codes for a complete claim:
1. The Vaccine Product Code (The Syringe)
This code represents the cost of the biological product itself.
- CPT Code: 90681
- Descriptor: Respiratory syncytial virus vaccine, pre-filled syringe, for intramuscular use.
Important Note: Initially, many people confused Arexvy with the maternal RSV vaccine. Code 90681 is specifically for the GSK Arexvy product for older adults. Do not use code 90679 (which is for the Pfizer Abrysvo) or the pediatric codes (which start with 903).
2. The Administration Code (The Nurse’s Time)
This code covers the cost of the staff member preparing and injecting the vaccine, plus the supplies (syringe, alcohol wipe, bandage).
For Arexvy, you will generally use one of two codes depending on the patient’s insurance type:
- 90471 (Standard administration): Immunization administration for one vaccine (single or combination), any route. Use this for commercial insurance or private pay.
- G0008 (Medicare specific): Administration of a vaccine (not influenza or pneumococcal). Medicare requires this specific HCPCS code for RSV vaccine administration.
Do not use 90472 (that is for additional vaccines given on the same day).
Quick Reference Table: Arexvy CPT Codes
| Component | Code | Description | Who uses it? |
|---|---|---|---|
| Product (Drug) | 90681 | RSV vaccine (Arexvy), adjuvanted, for IM use | All payers (Medicare, Medicaid, Commercial) |
| Admin (Commercial) | 90471 | Admin of one vaccine | Private insurers (Blue Cross, Aetna, UnitedHealthcare) |
| Admin (Medicare) | G0008 | Admin of vaccine (except flu/pneumococcal) | Medicare Part B |
| Admin (Medicaid) | 90471 or specific state code | Varies by state | Check your state’s fee schedule |
How to Bill Arexvy: A Step-by-Step Guide
Let’s walk through a realistic scenario. Margaret is 72 years old. She walks into your pharmacy for her flu shot. You ask if she wants the new RSV vaccine, Arexvy, too. She says yes.
Here is how your billing software should look.
Step 1: Verify Medical Necessity (For Medicare)
Unlike the flu shot, RSV vaccination for seniors falls under Medicare Part D (the prescription drug benefit), not Part B.
- Wait, what? Yes. This is the biggest change. The Inflation Reduction Act made ACIP-recommoved vaccines for adults free, but they go through Part D, not Part B.
- Exception: If the patient has a Medicare Advantage plan (Part C) , you need to check their medical policy. Some cover it under medical benefits; others use pharmacy networks.
Step 2: Enter the Codes
In your claim form (CMS-1500 or electronic equivalent):
- Box 24 (CPT Code): Enter 90681 (Arexvy product).
- Box 24 (CPT Code line 2): Enter G0008 (If Medicare) or 90471 (If Commercial).
- NDC Number: You must include the 11-digit National Drug Code for the specific lot of Arexvy. Missing the NDC is the #1 reason for denial.
- Example NDC format: 58160-1234-11 (Check your vial label).
Step 3: Modifiers (Usually None)
Generally, RSV vaccines do not require modifiers like -25 (Significant, separately identifiable E/M service) unless the patient had a full office visit for a sick problem and asked for the vaccine. Usually, you use the standard vaccine administration modifier (if required by your payer—often Modifier 52 for reduced services is not needed).
Arexvy vs. Abrysvo: Coding Differences
You cannot talk about Arexvy without mentioning Abrysvo (Pfizer). Both are RSV vaccines for older adults, but they are different products.
Here is the critical distinction.
| Feature | Arexvy (GSK) | Abrysvo (Pfizer) |
|---|---|---|
| CPT Product Code | 90681 | 90679 |
| Adjuvant | Yes (AS01E) | No (Non-adjuvanted) |
| Age Indication | 60+ | 60+ (and pregnancy 32-36 weeks) |
| Formulation | Pre-filled syringe | Powder + diluent (reconstitution) |
Why this matters: If you bill 90681 but you actually gave Abrysvo, you are committing fraud. If you bill 90679 but gave Arexvy, your claim will be denied for mismatched NDCs. Always scan the vial and verify the CPT matches the manufacturer.
Common Billing Mistakes (And How to Avoid Them)
Even experienced billers slip up when new vaccines launch. Here are the top three errors I see with the Arexvy CPT code.
Mistake #1: Using an “Unlisted” Code
Some early adopters, before the AMA released the specific code, used 90749 (Unlisted vaccine/toxoid). This is now incorrect. You must use 90681. Payers will automatically reject 90749 for Arexvy because a specific code exists.
Mistake #2: Forgetting the NDC on the Claim
Commercial insurers are strict. Medicare is ruthless. If you do not include the 11-digit NDC, the units, and the cost, your claim will hang in limbo for 30+ days.
- Tip: Ensure your billing software has a field for “NDC Qualifier” (code “N4”).
Mistake #3: Billing the Wrong Administration Code for Medicare
You know the flu shot uses G0008? Wait. No. The flu uses G0008.
- Flu: G0008.
- Pneumococcal: G0009.
- Hepatitis B: G0010.
- RSV (Arexvy): Also G0008.
Yes, it is confusing. G0008 is the “catch-all” for most non-flu, non-pneumococcal vaccines under Medicare Part B. However, because RSV goes through Part D, you might actually use a Pharmacy claim (NCPDP) format rather than a medical claim (CMS-1500). If you are a doctor’s office billing medical, check if the patient has a Medicare Part D plan before using G0008.
Reimbursement Rates (Realistic Estimates)
Let’s talk money. GSK sets a list price, but what you actually get paid depends on the payer.
- List price for Arexvy (drug): Approximately 280to295 per dose (as of late 2025).
- Administration fee: Varies by state and plan.
- Medicare Part D: Plans negotiate this. Usually between 30and75.
- Commercial insurance: Usually 80% coinsurance after deductible for the admin fee, but the vaccine is free under the ACA if preventive.
Important Note: Under the Inflation Reduction Act, adults on Medicare Part D should pay $0 out-of-pocket for Arexvy because it is an ACIP-recommended vaccine. If a patient is billed a copay, they should appeal.
Patient Scenarios: Real-World Coding
Scenario A: The Dual Vaccination Day
A 68-year-old patient wants the flu shot and Arexvy at the same visit.
- Billing:
- Line 1: 90681 (Arexvy) + 90471 (First vaccine admin)
- Line 2: 90658 (Flu shot) + 90472 (Second vaccine admin – add-on code)
- Note: You cannot bill 90471 twice. One is full price, the second is the add-on code.
Scenario B: The Medicare Patient in a Pharmacy
A 74-year-old comes to your in-store clinic.
- Billing: You will likely use the Pharmacy Benefit Manager (PBM) system.
- Codes: NCPDP fields. You will still reference 90681 as the product code, but the billing format is completely different (Bin, PCN, Group). Ask your pharmacist for the “Medical Benefit vs. Pharmacy Benefit” determination.
Scenario C: The Uninsured Patient
A 65-year-old has no insurance.
- Billing: You do not need a CPT code for the patient. You simply charge them cash.
- Cost: You may sell the vaccine for $350 (including your markup and admin fee). You do not submit a claim.
Frequently Asked Questions (FAQ)
Q1: Is there a different CPT code for the second dose of Arexvy?
A: Currently, no. Arexvy is approved as a single dose. Booster doses are being studied but do not have a specific CPT code yet. If a second dose is recommended in the future, the AMA will release a new code or modifier. For now, use 90681 only once per patient.
Q2: My EHR is showing code 90678. Is that for Arexvy?
A: No. 90678 is for a different RSV vaccine (palivizumab – Synagis) used for high-risk infants. Never use this for an adult. Stick with 90681.
Q3: Does Arexvy require a diagnosis code (ICD-10) on the claim?
A: Yes. For preventive vaccines, use Z23 (Encounter for immunization). Do not use an RSV diagnosis code (J12.1, J21.0) because the patient does not have RSV; they are preventing it.
Q4: Can I bill for an office visit (E/M code) plus the Arexvy CPT code?
A: Only if the patient had a medically necessary problem separate from the vaccine. For example, if they came for chest pain and decided to get the vaccine, you bill the E/M code (99213) with Modifier -25, plus the vaccine codes. If they only came for the shot, do not bill an E/M code.
Q5: What is the NDC for Arexvy?
A: The NDC varies by lot and packaging. As of publication, one common NDC for the pre-filled syringe is 58160-1242-11. Always verify the NDC on the physical box before billing.
Additional Resources & Links
To ensure you stay up to date with the latest coding changes for Arexvy, bookmark these official resources:
- CDC Vaccine Price List: cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/
- AMA CPT Code Search (Check for changes): ama-assn.org/cpt
- CMS Medicare Part D Vaccine Payment: cms.gov/medicare/payment/part-d-vaccines
Conclusion
Mastering the Arexvy CPT code is straightforward once you remember the product code 90681 and the distinction between commercial administration (90471) and Medicare pathways (G0008). Always include the specific NDC and the Z23 diagnosis code to avoid costly claim rejections. By following this guide, you can confidently bill for RSV protection, ensuring your senior patients stay healthy and your practice stays profitable.
