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Vaccine Coding - CPT codes

Vijayarani Sivakumar

Published On - February 28, 2022

Vaccines Administered at Well-child Visits

When vaccines are provided as part of a well-child encounter, the ICD-10 guidelines instruct that code Z00.121 or Z00.129 (routine health check for child over 298 days old) includes immunizations appropriate to the patient's age. Code Z23 may be used as a secondary code if the vaccine is given as part of a preventive health care service, such as a well-child visit.

ICD-10 for Combination Vaccines

ICD-10 requires only one code (Z23) per vaccination, regardless if single or combination. Report Z23 for all vaccination diagnoses.

Evaluation and Management Services Provided on the Same Date as Vaccine Administration

When an evaluation and management service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the evaluation and management service to indicate that this service was significant and separately identifiable from the physician's work of the vaccine counseling/administration.

Example: A patient presents for a visit to evaluate the control of his/her diabetes and at the same visit receives an influenza vaccine administration. A physician might report code 99213-25 with diagnosis code E11.9 in addition to the appropriate flu vaccine and administration codes.

Adding National Drug Codes (NDC) to Claims

Medicaid plans and private payers may require the inclusion of a vaccine product's National Drug Code (NDC) on your claim line for each vaccine product. This can be a bit confusing if the product is labeled with a 10-digit NDC, as HIPAA requires that NDC have 11-digits. To correctly report the NDC in the HIPPA format, you may have to translate the NDC.

The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format. Some drug products are labeled in 4-4-2, 5-3-2, or 5-4-1 formats. To change these codes to the 11-digit format, a zero is placed within the product code to create the 5-4-2 format.

Here are some examples showing addition of a zero to create this format:

Reporting Administration per Component

The pediatric immunization administration with counseling codes are:

90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

+90461: Each additional vaccine/toxoid component administered (list separately in addition to code for primary procedure)

These codes are reported per vaccine/toxoid component. CPT defines a component for these purposes as each antigen in a vaccine that prevents disease(s) caused by one organism. Combination vaccines are those vaccines that contain multiple vaccine components.
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You may report multiple units of code 90460 for each first vaccine/toxoid component administered. No modifier should be required when reporting multiple first components. Note also that code 90460 does not apply only to combination vaccines, but also to single component vaccines (such as influenza, human papilloma virus, or pneumococcal conjugate vaccines). This base code is reported for each vaccine administration to patients 18 years of age and under who receive counseling about the vaccine from a physician or qualified health care professional at the time of administration. Code 90461 is an add-on code reported for each additional vaccine component administered.

Report codes 90471-90474 for immunization administration of any vaccine that is not accompanied by face-to-face physician or other qualified health care professional counseling the patient and/or family, or for patients over 18 years of age.

Items of Note About Codes 90460 and 90461

To correctly report vaccine counseling and administration with these codes, it is important to recognize what the codes do and do not include.

These codes are limited to immunization administration, meaning purchased vaccine products must be separately reported.

A face-to-face service where a physician or other qualified health care professional (qualified per state licensure) provides counseling to the patient and/or caregivers is required to report 90460-90461. 

In the absence of counseling, the administrations must be reported with codes 90471-90474.

90460-90461 are reported for administration to patients 18 years of age and under.

Code 90460 is reported for each separate administration of single component vaccines and/or first component of a combination vaccine.

When reporting administration of combination vaccines, code 90460 is reported for the first component and add-on code 90461 is reported for each additional component (no modifier -51 required).

Note that route of administration (whether injection, oral, or intranasal) does not matter, since the codes include “via any route of administration.”

Administration Coding Example

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza (90660) vaccines. The physician documents the discussion. The mother signs consent to administration of these vaccines. A nurse prepares and administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are:
99393 - Preventive service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)

CPT designates six codes to report vaccine administration. Here's how to make sure you are reporting the correct service and conditions.

CPT® designates six codes to report vaccine administration, which are divided into two main categories:

Category 1: Administration with Counseling

90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered

+90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

To report these codes, provider documentation must substantiate three elements:

1. Patient age. These codes apply only to those patients age 18 years or younger. For patients older than 18 years old, you must turn to the second category of administration codes, detailed below.

2. Face-to-face counseling with the patient and/or family. Parents with children often have questions about vaccines, and the provider may spend significant time on education and counseling. Documentation of the encounter should detail the vaccines given and summarize patient risk factors or concerns, and information shared with the patient/family (e.g., possible side effects and benefits of the vaccine). If the provider does not document face-to-face counseling, he must turn to the second category of administration codes, detailed below.

3. The number of vaccine or toxoid components - NOT the number of individual vaccines - administered. Report 90460 for the first component administered, and one unit of 90461 for each additional component administered. For example:

• HPV vaccine includes a single component (90460)

• Td vaccine includes two components (90460, 90461)

• DTaP and Tdap vaccines include three components (90460, 90461 x 2)

• DTaP-Hib vaccine includes four components (90460, 90461 x 3)

• DTaP-Hib-IPV vaccine includes five components (90460, 90461 x 4)

The route of administration (subcutaneous, intranasal, etc.) is not relevant when reporting 90460 and 90461.

Category 2: Administration without Counseling

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

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)

90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)

Several factors distinguish these vaccine administration services 90460 and 90461, all of which are significant for code selection and provider documentation:

• 90471-90474 do not include counseling. These are the correct codes to report when the provider does not document counseling with the patient and/or family regarding the vaccine administration.

• 90471-90474 do not specify patient age. You may report these codes for patients of any age.

• 90471-90474 specify the route of administration. Report 90471-90472 for percutaneous, intradermal, subcutaneous, or intramuscular injections. Report 90473-90474 for administration by intranasal or oral route.

• 90471-90474 are reported per vaccine, rather than per vaccine component.

Report 90471 and 90473 are for the initial or first vaccine administered, depending on the route of administration. You may use only one initial administration code per patient encounter. When both an injected and an oral/intranasal vaccine are administered during the same visit, report 90471 as the initial administration code. If the provider administers multiple vaccines, report each additional vaccine administration using either 90472 and/or 90474, as appropriate to the route of administration. For example:

• To report a single intramuscular vaccination, report 90471.

• To report three intramuscular injections, report 90471 for the initial intramuscular vaccination administration and 90472 x 2 for the additional intramuscular administrations.

• To report two intramuscular injections, one oral administration, and one nasal administration, report 90471 (initial intramuscular vaccination administration), 90472 (additional intramuscular administration), and 90474 x 2 (one unit for each oral/nasal administration).

Mix and match codes when counseling for some (but not all) administrations

You can mix and match 90460-90461 and 90471-90474 if the provider counsels the patient on some, but not all, of the vaccines or vaccine/toxoid components administered. For example, if counseling is performed for HPV vaccine but not for an influenza vaccine provided at the same visit, report 90460 for the HPV administration with counseling, and either 90472 (injected) or 90474 (oral/intranasal) for administration of the influenza vaccine without counseling.

Don't forget the vaccine supply and diagnosis

In addition to vaccine administration, you typically may report the vaccine supply using a separate CPT® or HCPCS supply code. For example, to report the administration and supply of DTaP; measles, mumps, and rubella (MMR); and, Varicella vaccines, select:

90700 (DTaP Vaccine, IM)

90707 (MMR Vaccine, SQ or Jet Injection)

(90716) Varicella Virus Vaccine, SQ

(90471) Administration of DTaP, IM

(90472 x 2) Administration of MMR and Varicella Virus Vaccine

Note: The Vaccines for Children (VFC) program provides free vaccines for children under the age of 18 who meet certain criteria. If the provider participates in VFC, he or she may not separately charge for the vaccine supplies provided as part of the program; however, providers may charge for the vaccine administration(s). Check with your state VFC program and local carriers for specific coding rules.

Finally, note that all vaccines and immunizations are reported using ICD-10-CM code Z23 Encounter for immunization.