Vaccine Administration Codes

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

90472 Each additional vaccine injection (single or combination vaccine/toxoid) (List separately, in addition to code for primary procedure)

90473 Immunization administration by intranasal or oral route: 1 vaccine (single or combination vaccine/toxoid) (Do not report 90473 in conjunction with 90471)

90474 Each additional vaccine by intranasal or oral route (single or combination vaccine/toxoid) (List separately, in addition to code for primary procedure)

Billing Medicare for immunizations

Medicare Part B covers the cost of influenza and pneumococcal (both PPSV23 and PCV13) vaccines, as well as hepatitis B vaccine for persons at increased risk of hepatitis B. Medicare Part B does not cover other vaccinations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin, and Td/Tdap for wound management. Therefore, in the absence of injury or direct exposure, preventive immunization against diseases such as pertussis, diphtheria, etc., is not covered under Medicare Part B. These vaccines and other commercially available vaccines (such as zoster) typically are covered by Medicare Part D drug plans when they are ACIP-recommended to prevent illness. Billing for Part D vaccines goes directly to the
third-party drug coverage plan.

Though not reimbursed directly through the Medicare Physician Fee Schedule, the administration of influenza, pneumococcal, and hepatitis B vaccines (HCPCS codes G0008, G0009, and G0010) is reimbursed at the same rate as CPT code 90471 for the year that corresponds to the date of service of the claim

Overview

Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunizations (vaccination or inoculation) against such diseases as smallpox, typhoid and polio, are not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits which are primarily for the purpose of administering a non-covered injection).
Guidelines Refer to the Applicable Codes for Medicare covered (Part B), Medicare non-covered, and Medicare possibly covered (Part D) immunizations.

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Coding Clarification: Vaccines listed as Medicare Covered for Hepatitis B are eligible for Medicare Part B coverage if there has been a documented exposure, injury or risk factor. For Hepatitis B, coverage is limited to those who are at high or intermediate risk of contracting Hepatitis B.High risk groups are identified as:

  • ESRD patients
  • Hemophiliacs who receive Factor VIII or IX concentrates
  • Clients of institutions for the mentally retarded
  • Persons who live in the same household as a hepatitis B virus (HBV) carrier
  • Homosexual men
  • Illicit injectable drug abusers
  • Persons diagnosed with diabetes mellitus. (Rev. 170, 01-01-13) Intermediate risk groups are identified as:
  • Staff in institutions for the mentally retarded
  • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work (V05.3)

CPT Code Description
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

Vaccine administration coding

Report codes 90460 and 90461 only when the physician or qualified health care professional provides face-to-face counseling of the patient/family during the administration of the vaccine.

For immunization administration of any vaccine that is not accompanied by face-to-face counseling of the patient/family or for administration of vaccines for patients over 18 years of age, report codes 90471-90474.

Code 90460 is reported once for the first component of each vaccine or toxoid administered by any route. The reporting of code 90460 includes counseling for the first vaccine component. Code 90461 is additionally reported for the counseling associated with each additional component of any combination vaccine or toxoid.

CPT Coding Guidelines

• 90460 Through 18 years via any route with counseling by physician or other qualified health care professional; first vaccine/toxoid component. Medicaid rate as of 7/1/2015 is $21.68
• 90461 Through 18 years via any route, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component. Medicaid rate is $0.00
• 90471 (including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid). Medicaid rate as of 7/1/2015 is $21.68
• 90472 (including percutaneous, subcutaneous, intradermal, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid). Medicaid rate as of 7/1/2015 – $12.59

How does CPT define a vaccine component?

A component refers to all antigens in a vaccine that prevent disease(s) caused by one organism. Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of vaccines.

Combination vaccines are those vaccines that contain multiple vaccine components. Conjugates or adjuvants contained in vaccines are not considered to be component parts of the vaccine as defined above.

ICD-10
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for any vaccine given including influenza is Z23 (encounter for immunizations).

NCCI Edits Coding & Billing Tips

NCCI Edits
• The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication
• The version effective 1/1/2013 included edits on all E/M services that disallow patient visit with immunization administration codes without the proper modifier
• With proper modifier placement, the edit can be overridden

TIPS on Coding to avoid denials

• Append modifier 25 to the preventive medicine service code (99381-99395) when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474). Modifier 25 should also be appended to other non-preventive medicine E/M services (e.g., 99201-99215) when reported in conjunction with immunization administration — but only when the E/M service is significant and separately identifiable. So…anytime a vaccine is administered, whether it is a WCC
or acute visit a -25 modifier needs to be added to the E/M code.

• If a WCC and acute visit is done at the same visit, and shots are administered a -25 modifier needs to be attached to both the WCC and the acute visit code.
• No modifier needed if shots only.
• Add modifier -25 to the sick visit code if both a well and a sick visit are coded and no immunizations are given.
• If you have G8431/G8510 (depression screen) with a vaccine admin, add the -25 modifier to G8431/G8510.
• Use both modifiers if you have CPT 99173, G8431/G8510, and a vaccine admin.
• NCCI prohibits the use of procedure code 99211 (office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician) with vaccine/immunization administration procedure codes 90460-90474. No NCCI bypass modifiers are recognized with these procedure code pairs.

I. GENERAL INFORMATION

A. Background: This change request provides instructions for claims processing and FISS edits to be updated to allow HCPCS code G0010 (Administration of hepatitis B vaccine) to be billed by OPPS providers effective for claims with dates of service on or after January 1, 2011.

In CR 7342, Transmittal 2174, dated March 18, 2011, CMS retroactively assigned HCPCS code G0010 to APC 0436, Level I, Drug Administration, and changed the status indicator for HCPCS code G0010 from status indicator “B” to status indicator “S” effective January 1, 2011.

CR 7342 also provided guidance to providers to report HCPCS G0010 when billing for the administration of hepatitis B vaccines under the OPPS rather than CPT code 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)) or CPT code 90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)) for services performed beginning January 1, 2011, to ensure the correct waiver of coinsurance and deductible. At the time of the release of CR 7342, the manual was not updated to reflect this revised billing guidance. CMS is updating Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section 10.2.1, to reflect the current billing instructions.

HCPCS Definition
*90471 Immunization administration. (For OPPS hospitals billing for the hepatitis B vaccine administration)

  • NOTE: For claims with dates of service prior to January 1, 2006, OPPS and non-OPPS hospitals report G0010 for hepatitis B vaccine administration. For claims with dates of service January 1, 2006 until December 31, 2010, OPPS hospitals report 90471 or 90472 for hepatitis B vaccine administration as appropriate in place of G0010. Beginning January 1, 2011, providers should report G0010 for billing under the OPPS rather than 90471 or 90472 to ensure the correct waiver of coinsurance and deductible for the administration of hepatitis B vaccine.

Immunization administration codes

If the patient receiving the influenza vaccine is 18 years of age or younger and receives counseling from a physician or other qualified health care professional (e.g., nurse practitioner), report 90460 for either the injection or intranasal.

90460 – Immunization administration through 18 years of age via any route of administration, w/ counseling by physician or other qualified health care professional; first vaccine/toxoid component However, if both of the above criteria are not met, the immunization administration code reported must come from the 90471-90474 series. Clinical staff (e.g., R.N., L.P.N.) do not meet the criteria for other qualified health care professional per CPT guidelines.

90471- IA; one vaccine (single or combination vaccine/toxoid)

News Articles, Coding Corner, Administration/Practice Management, Billing & Coding, Influenza
+90472- IA; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to 90460, 90471 or 90473.)
90473 – IA; one vaccine (single or combination vaccine/toxoid)
+90474- IA; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to 90460, 90471 or 90473.)
Other considerations to keep in mind when reporting codes 90471-90474:

  • If you administer an injection of the influenza vaccine only, report 90471.
  • If you administer the intranasal influenza vaccine only, report 90473.
    If you administer an influenza vaccine in addition to other vaccines, report the influenza injection with 90472 or the intranasal with 90474.

Note that code 90471 or 90473 cannot be reported in conjunction with 90460. Therefore, if during a single encounter, a patient receives multiple vaccines and there is counseling on all but the influenza vaccine, report 90472 or 90474 in addition to 90460 and 90461 as appropriate.

The International Classification of Diseases, Tenth Revision, Clinical Modification code for the influenza vaccine is Z23.

Vignettes

A 12-year-old is seen for her well-child check and vaccines. She receives tetanus, diphtheria and acellular pertussis (Tdap), human papillomavirus (HPV) and meningococcal vaccines in addition to the intranasal influenza vaccine. The physician counsels on all of the vaccines. Report the following IA codes:

90460 x4 (tetanus component; meningococcal; influenza; HPV)
90461 x2 (diphtheria and pertussis component)

To code for the same scenario as above except that the physician does not document counseling for the intranasal influenza or Tdap vaccine but does document counseling for meningococcal and HPV vaccines, report:

90460 x2 (meningococcal; HPV)
90472 x 1 (Tdap)
90474 x 1 (influenza)

A 9-month-old presents with her father to receive her second dose of the influenza vaccine. A registered nurse sees the patient, does a brief assessment, receives consent from the father and administers the vaccine.

Report:

90471 (influenza)

It is important to remember that reporting an evaluation and management service in addition to immunization administration codes will depend on several factors. This becomes an issue when patients present outside of their routine well check to receive vaccines. Many practices set up flu clinics where patients can receive their
annual influenza vaccines and are seen solely by clinical staff.

• Billing for Multiple Administrations:
When administering more than one immunization on the same date of service, providers should bill as described above for the first administration. The appropriate procedure code(s) for additional immunization administrations (90472 and/or 90474) should then be listed with the appropriate number of units for the additional vaccine(s). The specific CPT code(s) for the additional vaccine(s) administered should be listed on subsequent line(s) following the appropriate administration code. The number of specific vaccines listed after each immunization administration code should match the number of units listed for each administration code. • Appropriate Use of CPT E/M Codes with Immunization Administrations: If a significant, separately identifiable medically necessary E/M service is performed, an appropriate Evaluation and Management (E/M) code may be reported in addition to the vaccine and the immunization administration codes. This must be reflected in the medical record
documentation.

AllWays Health Partners Reimburses

• Adult vaccine administration codes when not reported with an E/M service
• Pediatric vaccine and immunization counseling, when properly documented in the member’s medical record
• Pediatric vaccine administration when not reported with an E/M service
AllWays Health Partners Does Not Reimburse
• Combined vaccines when the individual components are available and supplied by a government entity.
• Provision of a vaccine when the following conditions are present:

  • The provider is eligible to receive the vaccine used to immunize the AllWays Health Partners member, at no cost, under the auspices of a government vaccine distribution program.
  • The vaccine the provider administered is available under a government program.
  • The AllWays Health Partners member receiving the vaccine is a qualified recipient under the vaccine distribution program.
  • The vaccine is administered to an AllWays Health Partners member when the member does not fall into a risk group for whom the immunization is recommended.
    • State-supplied vaccine cost(s)
    • Unlisted Services and Procedures
    • Vaccine administration codes reported standalone (i.e. without code specifying which vaccine or toxoid is being administered)
    • Vaccines not approved by the FDA
    • Vaccines administered as part of a workplace requirement Procedure Codes

Provider Payment Guidelines and Documentation

• Submit a CPT® vaccine/toxoid product code for each administered vaccine/toxoid product on a single claim line, with a count of one.
• Append Modifier SL to each CPT® vaccine/toxoid product code in the first modifier field when the vaccine is state-supplied. (AllWays Health Partners uses post payment audit data to confirm compliance with the billing guidelines for State-supplied vaccines.)
• Submit appropriate CPT vaccine/immunization administration code(s) as follows:

  • For administration and physician counseling (CPT 90460-90461) of multiple component vaccines, provided to children 18 years of age or younger, submit 90460 for the first component administered, and 90461 for each additional component included in the vaccine.
  • Report one initial administration code per day, regardless of vaccine administration method.
  • Do not bill CPT codes 90460, 90471, and 90473 together on the same date of service.
  • When one of the initial administration codes is billed, report all additional vaccine/toxoid components administered with the appropriate add-on code (i.e. 90461, 90472 or 90474).
  • For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family, or for administration of vaccines to patients over 18 years of age, report codes 90471-90474. Submit as follows:

CPT Code
CPT Short Descriptor Code(s) To Be Reported
90471 Immunization admin 90471 X