When it comes to administering vaccines, it’s crucial for healthcare providers to have a clear understanding of the appropriate codes to use for billing and coding purposes. One of the key codes in this process is the 90471 CPT code. This code is specifically used for the administration of vaccines, whether it’s a single vaccine or a combination vaccine/toxoid.
The 90471 CPT code covers various routes of administration, including percutaneous, intradermal, subcutaneous, or intramuscular injections. It is important to note that this code applies to patients of all ages, making it a versatile code to use in various healthcare settings. Furthermore, the service limit for this code is one per day, ensuring accurate reporting and billing practices.
As healthcare providers, it is essential to familiarize ourselves with the guidelines and requirements surrounding the 90471 CPT code. By doing so, we can ensure proper documentation, accurate reporting, and compliance with coding regulations.
In this article, we will explore the key aspects of the 90471 CPT code, including its usage in different scenarios, documentation requirements, reimbursement considerations, and more. By gaining a comprehensive understanding of this code, we can enhance our coding practices and ensure seamless operations in our healthcare facilities.
Key Takeaways:
- The 90471 CPT code is used for the administration of vaccines.
- This code covers various routes of administration and can be used for patients of any age.
- The service limit for the 90471 CPT code is one per day.
- Proper documentation and compliance with coding regulations are essential when using this code.
- Understanding the guidelines and requirements surrounding the 90471 CPT code is crucial for accurate reporting and billing.
Vaccines Administered at Well-child Visits
When vaccines are provided as part of a well-child encounter, we follow the ICD-10 guidelines. These guidelines state that code Z00.121 or Z00.129 (routine health check for child over 298 days old) includes immunizations appropriate to the patient’s age. As a secondary code, we may use code Z23 if the vaccine is given as part of a preventive health care service, such as a well-child visit.
ICD-10 requires only one code (Z23) per vaccination, regardless of whether it is a single or combination vaccine.
When billing for well-child visits that include vaccine administration, it is important to accurately code the services performed. By following the appropriate ICD-10 guidelines and using the correct codes, healthcare providers can ensure proper reimbursement and compliance with coding regulations.
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.
| Evaluation and Management Service Code | Description |
|---|---|
| 99213-25 | Office or other outpatient visit for the provider to evaluate and manage an established patient, with the visit involving a separately identifiable evaluation and management service, in addition to the vaccine counseling/administration |
By appending the modifier -25 to the evaluation and management service code, healthcare providers can indicate that the service was distinct from the vaccine administration, ensuring accurate billing and reimbursement. This allows for proper documentation and recognition of the physician’s significant work during the encounter.
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.
Example of NDC format translation:
| 10-Digit NDC | 11-Digit HIPAA Format NDC |
|---|---|
| 12345-6789-10 | 12345-0678-9 |
| 98765-4321-00 | 98765-0432-10 |
Reporting Administration per Component
When it comes to reporting the administration of pediatric immunizations, it is important to understand the guidelines for coding. Specifically, there are two codes to be aware of: 90460 and +90461.
The first code, 90460, should be used for the first or only component of each vaccine or toxoid administered. This code is reported per vaccine or toxoid component, and it should be listed separately in addition to the code for the primary procedure.
For each additional vaccine or toxoid component administered, the code +90461 should be used. Similar to 90460, this code is reported per vaccine or toxoid component and should be listed separately in addition to the primary procedure code.
It is important to note that combination vaccines, which contain multiple vaccine components, fall under these coding guidelines. By following these guidelines, healthcare providers can accurately report the administration of vaccines and ensure compliance with coding regulations.
Example of Reporting Administration per Component
| Vaccine | Components | Primary Procedure Code | Additional Component Codes |
|---|---|---|---|
| Tdap | Tetanus, Diphtheria, Pertussis | 90471 | +90461 |
| MMR | Measles, Mumps, Rubella | 90471 | +90461 |
| Pneumococcal Conjugate | Pneumococcal Serotypes | 90471 | +90461 |
Items of Note About Codes 90460 and 90461
To correctly report vaccine counseling and administration with codes 90460 and 90461, 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 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.
| CPT Code | Description |
|---|---|
| 90460 | Immunization administration, including percutaneous, intradermal, subcutaneous, or intramuscular injections; single vaccine/toxoid component |
| +90461 | Immunization administration, including percutaneous, intradermal, subcutaneous, or intramuscular injections; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) |
Vaccines for Children (VFC) Immunization Service CPT Codes
When it comes to administering vaccines to patients up to 18 years and 11 months of age, healthcare providers rely on the Vaccines for Children (VFC) Immunization Service CPT codes. These codes ensure proper reimbursement and documentation for the vaccination services rendered. Let’s take a closer look at the specific codes and their usage.
CPT Code 90471: One Vaccine Administration
A primary vaccine administration is represented by CPT code 90471. This code is used when a healthcare professional administers a single vaccine to a patient. It covers the percutaneous, intradermal, subcutaneous, or intramuscular injection of the vaccine.
CPT Code 90472: Each Additional Vaccine Administration
In cases where multiple vaccines are administered during a single encounter, CPT code 90472 is used to report each additional vaccine administration. This code accounts for the administration of supplementary vaccines following the initial administration represented by CPT code 90471.
CPT Code 90473: One Vaccine Administration by Intranasal or Oral Route
For vaccines that are administered through intranasal or oral routes, such as nasal sprays or oral drops, healthcare providers utilize CPT code 90473. This code represents the administration of a single vaccine using these specific routes of delivery.
CPT Code 90474: Each Additional Vaccine Administration by Intranasal or Oral Route
Similar to CPT code 90472, CPT code 90474 is used to report each additional vaccine administration by the intranasal or oral route. This code is specific to cases where multiple vaccines are administered through these alternative routes.
It is important to note that when billing for vaccines administered as part of the VFC program, these specific CPT codes should be used along with the “SL” modifier. This combination ensures accurate reporting and reimbursement.
Here is a visual representation of the CPT codes mentioned:
| CPT Code | Description |
|---|---|
| 90471 | One vaccine administration |
| 90472 | Each additional vaccine administration |
| 90473 | One vaccine administration by intranasal or oral route |
| 90474 | Each additional vaccine administration by intranasal or oral route |
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General Vaccine Information
Vaccine codes play a crucial role in accurately billing and coding the administration of vaccines. As healthcare providers, it’s essential to stay up to date with the latest vaccine codes published by the American Medical Association (AMA), which are released semi-annually. These codes classify vaccines based on their target population, whether pediatric, adolescent, or adult. When coding, it’s crucial to confirm that the administered vaccine is appropriate for the patient’s age to ensure accurate reporting.
For vaccine administration, there are three general categories of codes:
- 90471-90474: These codes are used for vaccines administered without counseling.
- 90460-90461: These codes are used for vaccines administered with counseling.
- 91300-91303: These codes are specific to COVID-19 vaccines.
It’s important to select the appropriate administration code based on the specific circumstances of the vaccination encounter. Proper understanding and utilization of these codes contribute to accurate reimbursement and compliance with coding regulations.
Example:
| Vaccine Code | Description |
|---|---|
| 90471 | Percutaneous, intradermal, subcutaneous, or intramuscular injection of one vaccine or combination vaccine/toxoid |
| 90472 | Each additional vaccine/toxoid component administered, sequential to 90471 (List separately in addition to code for primary procedure) |
| 90460 | Immunization administration through any route with counseling by physician or other qualified healthcare professional |
| 90461 | Each additional immunization administration through any route (List separately in addition to code for primary procedure) |
Noteworthy Mention:
The COVID-19 pandemic has brought increased attention to vaccine administration. To facilitate accurate reporting and reimbursement for COVID-19 vaccines, healthcare providers should use the appropriate COVID-19 vaccine administration codes (91300-91303) provided by the AMA. These codes are specific to the administration of COVID-19 vaccines and cover various scenarios and routes of administration.
Age-restricted vaccines
Some vaccines have specific age requirements and may be designated pediatric, adolescent, or adult. It is crucial for coders to verify that the vaccine administered is suitable for the patient’s age. Accurate documentation is essential to support proper coding and billing.
When administering vaccines, it is imperative to consider age restrictions. Different vaccines are recommended for specific age groups, such as infants, children, adolescents, and adults. Vaccines like the MMR (Measles, Mumps, Rubella) are typically given to children before they reach school age. On the other hand, vaccines like the Shingles vaccine are recommended for adults over a certain age.
Ensuring that the appropriate vaccine is administered based on age is critical for maintaining patient safety and effective disease prevention. When documenting vaccine administration, it is important to include the age of the patient to support accurate coding and billing.
Example:
A 2-year-old child visits a pediatrician for his routine immunization. The healthcare provider administers vaccines appropriate for the child’s age. The documentation must include the child’s age as 2 years to comply with coding guidelines.
| Vaccine | Age Group |
|---|---|
| DTaP (Diphtheria, Tetanus, Pertussis) | Pediatric |
| MMR (Measles, Mumps, Rubella) | Pediatric |
| HPV (Human Papillomavirus) | Adolescent |
| Flu (Influenza) | All age groups |
| Shingles | Adult |
Code Set Administration
When it comes to vaccine administration, proper coding is crucial for accurate billing and reimbursement. Vaccine administration is typically billed separately from the vaccine itself, and there are specific code ranges to identify vaccines with and without counseling, depending on the patient’s age. It is essential for providers to use the appropriate administration code for each vaccine administered during an encounter.
Codes for Vaccines with Counseling
When counseling is provided along with vaccine administration, the following codes are used:
| Code | Description |
|---|---|
| 90460 | 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 and should be used when a face-to-face service involving counseling is provided to the patient and/or caregivers.
Codes for Vaccines without Counseling
If counseling is not provided, then the following codes are used for vaccine administration:
| Code | Description |
|---|---|
| 90471 | Administration of vaccines (includes percutaneous, intradermal, subcutaneous, or intramuscular injections of one vaccine or combination vaccine/toxoid) |
| 90472 | Each additional vaccine/toxoid component administered (list separately in addition to code for primary procedure) |
Note: Combination vaccines are those that contain multiple vaccine components.
By using the appropriate administration code for each vaccine administered, healthcare providers can ensure accurate billing and compliance with coding regulations. Proper coding also facilitates reimbursement and helps track the administration of vaccines in patient records.
State Programs
Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. While the vaccines are provided by the state, providers may charge patients for the administration fee associated with providing the vaccine. The CPT code range for vaccines provided as part of the VFC program is 90476-90749, with the “SL” modifier appended.
Route of administration
When administering vaccines, it is important to consider the route of administration, as it determines the appropriate administration code to be used. While most vaccines are given as injections, there are also some vaccines that are administered orally or intranasally.
For vaccines administered through percutaneous, intradermal, subcutaneous, or intramuscular injections, the appropriate administration codes are 90471 and 90472. These codes are used to report the administration of single or combination vaccines or toxoids.
On the other hand, vaccines administered orally or intranasally are reported using administration codes 90473 and 90474.
It is crucial to correctly report the route of administration, as it ensures accurate billing and coding. By utilizing the appropriate administration codes based on the specific route, healthcare providers can ensure compliance and proper reimbursement.
Initial Vaccines
When multiple vaccines are administered during an encounter, it is important to specify an initial administration code for the first vaccine. This helps accurately report the vaccine administration and ensure proper reimbursement. There are two initial administration codes commonly used:
- 90471: Percutaneous, intradermal, subcutaneous, or intramuscular injections
- 90473: Intra-nasal or oral route
By using the appropriate initial administration code, healthcare providers can effectively document and bill for the first vaccine administered to the patient.
| Vaccine Administration Code | Route of Administration |
|---|---|
| 90471 | Percutaneous, Intradermal, Subcutaneous, or Intramuscular Injections |
| 90473 | Intra-nasal or Oral Route |
Subsequent vaccines
If more than one vaccine is administered on the same day, subsequent administration codes are required to document the additional vaccines. These codes are classified as add-on codes and must be reported with an initial administration code.
| Vaccine Administration Code | Route of Administration |
|---|---|
| 90472 | Percutaneous, Intradermal, Subcutaneous, or Intramuscular Injections |
| 90474 | Intra-nasal or Oral |
These subsequent administration codes, 90472 and 90474, are used to report additional vaccines administered after the initial vaccine. When using these codes, it is important to specify the route of administration for each vaccine.
Product Vaccine Examples
When it comes to reporting the administration of specific vaccines, there are various vaccine codes available. These codes play a crucial role in accurately documenting and billing for vaccines such as tetanus and diphtheria toxoids, HPV, influenza, and pneumococcal conjugate vaccines.
Here are some examples of vaccines and their corresponding codes:
| Vaccine | Code |
|---|---|
| Tetanus and diphtheria toxoids | 90471 |
| HPV | 90471 |
| Influenza | 90471 |
| Pneumococcal conjugate | 90471 |
By using these specific vaccine codes, healthcare providers can accurately report the administration of these vaccines, ensuring proper reimbursement and compliance with coding regulations.
Conclusion
In conclusion, the 90471 CPT code plays a critical role in accurately billing and coding the administration of vaccines. By adhering to the guidelines and requirements for documentation, age restrictions, route of administration, and reporting of vaccines, healthcare providers can ensure proper reimbursement and maintain compliance with coding regulations. It is essential to understand the different codes and their appropriate usage, as this knowledge greatly contributes to the efficient and effective management of immunization administration.
Proper documentation is crucial in ensuring accurate coding and billing for vaccine administration. Providers must carefully document the patient’s age to support the correct reporting of the administered vaccines. Additionally, the correct route of administration must be identified to assign the appropriate administration code. By accurately documenting these details, providers can confidently report the correct codes for each vaccine administered.
It is also important to note that there are different codes and modifiers for specific scenarios, such as evaluation and management services provided alongside vaccination administration. Providers should familiarize themselves with these specific coding requirements to ensure proper documentation and coding. By following these guidelines and staying up to date with the latest code publications, healthcare providers can effectively navigate the complexities of billing and coding for vaccine administration.
FAQ
What is the 90471 CPT code used for?
The 90471 CPT code is used for the administration of vaccines.
Can the 90471 code be used for patients of any age?
Yes, the 90471 code can be used for patients of any age.
How many times can the 90471 code be used in a day?
The service limit for the 90471 code is one per day.
Which ICD-10 codes are used for routine health check-ups that include immunizations?
The ICD-10 codes Z00.121 and Z00.129 are used for routine health check-ups that include immunizations for children over 298 days old.
What is the modifier -25 used for in relation to the 90471 code?
The modifier -25 is used to indicate that an evaluation and management service was provided on the same date as a prophylactic immunization.
Do Medicaid plans and private payers require the inclusion of an NDC on claims?
Yes, Medicaid plans and private payers may require the inclusion of a vaccine product’s National Drug Code (NDC) on claims.
How should an NDC be reported in the HIPAA format?
To report an NDC in the HIPAA format, the 10-digit NDC should be translated into a number that, if hyphenated, would appear in a 5-4-2 format.
What are the pediatric immunization administration codes?
The pediatric immunization administration codes are 90460 for the first component of each vaccine or toxoid administered, and +90461 for each additional component administered.
What does the 90460-90461 code range include?
The 90460-90461 code range includes immunization administration with counseling.
Are vaccine counseling and administration reported with the same codes?
No, vaccine counseling and administration are reported using different codes. Vaccine counseling and administration are reported with codes 90460-90461, while administration without counseling is reported with codes 90471-90474.
Which codes should be used for vaccines provided through the Vaccines for Children program?
Vaccines provided through the Vaccines for Children program should be billed with codes 90476-90749 with the “SL” modifier appended.
How are vaccines reported based on their route of administration?
Vaccines given as injections are reported with codes 90471 and 90472, while oral and intranasal vaccines are reported with codes 90473 and 90474.
How should multiple vaccines administered on the same day be coded?
The first vaccine administered on a given day should be coded using the initial administration codes 90471 or 90473. Subsequent vaccines administered on the same day should be coded using the subsequent administration codes 90472 or 90474.
Are there specific codes for different types of vaccines?
Yes, there are specific codes for certain vaccines, such as tetanus and diphtheria toxoids, HPV, influenza, and pneumococcal conjugate vaccines.
How important is it to use the correct codes for vaccine administration?
Using the correct codes for vaccine administration is crucial for accurate billing and coding, as well as ensuring proper reimbursement and compliance with coding regulations.