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  
0 Votes - Sign in to vote or comment.

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. 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Emergency Department - APC Reimbursement Method
September 15th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
Why Medical Coding and Billing Software Desperately Needs AI
September 7th, 2022 - Find-A-Code
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
CMS says Less Paperwork for DME Suppliers after Jan 2023!
August 18th, 2022 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare!  Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim. However, this is about ...
Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association