Vaccine Administration - When The Right Vaccine Code is Not Enough

September 30th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Preventive Medicine Service   CPT® Coding   HCPCS Coding   Pediatrics   Modifiers   Primary Care|Family Care  
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Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer guidelines for the exceptions. 

Immunization Administration Code Sets

90460- 90461: Used when the physician provides face-to-face counseling to the patient and/or family for patients through 18 years old.

90471-90474: Used in the absence of counseling for patients over age 18.

NOTE: When reporting codes 90476-90749, remember they identify the vaccine product only and you need to report the administration of a vaccine/toxoid. 90476-90749 must be used in addition to an immunization administration code(s) (90460, 90461, 90471, 90472, 90473, 90474).

AMA Guidelines also state: 

"Modifier 51 should not be reported with the vaccine/toxoid codes 90476-90749 when reported in conjunction with administration codes 904609046190471904729047390474."

Route of Administration Codes 90471-90474

To select the appropriate administration code, you must first know the route of administration of the vaccine itself. Injection routes are percutaneous, intradermal, subcutaneous or intramuscular. However, there are also a few oral and intranasal vaccines (90476, 90477, 90660, 90680, 90681 and 90690).

Most vaccines are given as follows:

  • Intramuscular (IM) injection: 90633, (HepA)
  • Subcutaneous (SC): 90707, Measles, mumps, and rubella virus vaccine
  • Intradermal (ID) injection: 90676, Rabies vaccine
  • Oral administration: 90680, Rotovirus vaccine
  • Intranasal spray application: 90660, Influenza virus vaccine

Initial Vaccines

If one or more vaccines are performed during an encounter, an initial administration code must be reported for the first component and an add-on code is used for the other. The initial administration codes include:

  • 90460 – through 18 years of age via any route of administration with counseling, first or only component of each vaccine or toxoid administered.
  • 90471 – Injectable vaccines (for example, percutaneous, intradermal, subcutaneous or intramuscular) both single and combination vaccines.
  • 90473 – Oral or intranasal vaccines, both single and combination vaccines.

Refer to the following rules for reporting:

  • Report only one initial administration code per claim.
  • Report counseling administration codes (90460-90461) before non-counseling administration codes (90471-90474).
  • Report administration codes for injectable vaccines (90471-90472) before oral or intranasal vaccines (90473-90474).

Subsequent Vaccines

If more than one vaccine is administered on the same day, additional administration codes are required to document the additional vaccines. Subsequent vaccine codes are classified as add-on codes and must never be reported without the initial administration code (90461, 90472, 90474). The definitions for the subsequent administration codes are as follows:     

  • 90461 Immunization administration through 18 years of age via any route of administration with counseling
  • 90472 – Injectable vaccines
  • 90474 – Oral or intranasal vaccines

Apply units to the subsequent administration code for every additional vaccine (two or more) of the same type (injectable or oral).

Note: The total number of units for the initial and subsequent administration codes should equal the total number of vaccines given. Refer to the following examples: 

2 Injectable Vaccines with Counseling under 18 years old

  • 90460 x1 unit (Initial)
  • 90461 x1 unit (Subsequent)             

5 Injectable Vaccines

  • 90471 x1 unit (Initial)         
  • 90472 x4 units (Subsequent)          

1 Intranasal, 2 Oral Vaccines           

  • 90473 x1 unit (Initial)
  • 90474 x2 units (Subsequent)

1 Injectable Vaccine with Counseling under age 18, 1 Oral Vaccine                            

  • 90460 x1 unit (Initial)                                           
  • 90461 x1 unit (Subsequent) 

4 Injectable Vaccines, 1 Oral Vaccine              

  • 90471 x1 unit (Initial)
  • 90472 x3 units (Subsequent)
  • 90474 x1 unit  (Subsequent)

HCPCS Administration Codes

When billing influenza, influenza H1N1, pneumonia or hepatitis B, the Centers for Medicare and Medicaid (CMS) require physicians to report HCPCS administration codes rather than CPT® administration codes. The HCPCS administration codes and the vaccine codes have a one-to-one relationship and are always paired together. Rules for reporting initial or subsequent vaccines do not apply. The HCPCS administration codes and the vaccines they are paired with are listed below:

If other vaccines are combined with these three G-codes, the standard CPT® administration codes (90460, 90461, 90471-90474) must be used to track the remaining vaccines.

Note: G-codes used for CMS follow different reporting guidelines than the CPT® administration codes (90460, 90461, 90471-90474). 

Age-Specific Vaccines

Certain vaccines specify age requirements. The definitions may indicate a date range, or they may be more generic and only state whether the patient was a pediatric patient or an adult. Make sure the patient’s age and the vaccine requirements do not contradict one another. The age-specific vaccines include the following: 90625, 90632, 90633, 90634, 90636, 90696, 90700, 90702, 90714, 90715, 90732, 90739, 90743, 90744 and 90746.

Vaccines and Evaluation and Management Codes

National Correct Coding Initiative (NCCI) edits do not allow 99211 to be billed with any vaccine administration codes (90460, 90461, 90471-90474). For separately billable evaluation and management (E/M) services performed on the same day as vaccines, add modifier 25 to the E/M code.

Reminder: Don't forget ICD-10-CM code Z23 - Encounter for immunization. 

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