Coding and billing vaccine administration in an outpatient setting is challenging because vaccine codes are based on several factors, with different codes for Medicare and private health plans. Medicare coverage on a routine basis is available only for a few vaccines. Moreover, sometimes a patient may require more than one vaccine during a visit, and selecting the correct serum code alone is not enough to ensure full reimbursement. Medical codes for vaccine administration depend on the route of administration, the number of components in the vaccine, and the patient’s age – specifying an age range or more generically, indicating pediatric, adolescent or adult.
It is also important to note that additional units should be reported for additional components of each vaccine. If the practice buys the vaccine, the accurate serum code must be reported; if the patient or state provides vaccine serum to the patient, only the administration should be reported.
To achieve maximum reimbursement, coders need to understand the different rules that apply in specific situations.
Factors governing Vaccine Code Reporting
- Route of Administration – This could be intramuscular, oral, or intranasal. The codes used here are in the CPT series: 90460 to 90474
- With Counseling – CPT codes 90460 and 90461 must be used when the physician or other qualified health professional provided immunization-related counseling for patients from birth to age 18 and/or family member
- With Multiple Components – CPT defines a component as referring to “all antigens contained 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 that have multiple vaccine components.
For vaccines with multiple components, the initial vaccination code must be reported first and then the add-on code for each additional component of the serum must be reported.
For example, if a two-month old baby is brought in for a well-child check and the parents have concerns about the immunizations, the physician explains the schedule and the rationale, and also spends time counseling the parents. If the baby receives a DTaP immunization, 90460 must be reported once and 90461, two units, as the physician provided counseling and there were three components to the vaccine. ICD-9-CM guidelines indicate that immunizations administered as part of a routine well-child check should be reported with code V20.2. Other additional codes can be reported if the specific payer requests them.
Medical coding applicable in this case is shown below:
| Vaccine | No: of vaccine components | Immunization Administration Code(s) Reported | ICD-9-CM Code Reported When Vaccine Administered During a Non-Preventive Medicine Visit |
| DTaP or Tdap | 3 | 90460,90461,90461 | V06.1 |
- Without Counseling (90471-90474) – 90471 and 90472 are used for vaccine administration by intradermal, subcutaneous or intramuscular injections: 90471 for the initial component, 90472 for each additional component, and 90473 and 90474 for oral or intranasal administration.
- Medicare Coverage for Vaccines – (G0008, G0009 and G0010) – In order to get the flu, pneumococcal and hepatitis B serums paid by Medicare, the medical practice must use HCPCS administration codes.
- Seasonal Influenza Virus Vaccine – G0008 with diagnosis code V04.81
- Pneumococcal Vaccine – G0009 with diagnosis code V03.82
- Seasonal Influenza Virus Vaccine and Pneumococcal Vaccine received during the same visit – G0008 – influenza virus, G009 – pneumococcal with diagnosis code – V06.6
- Hepatitis B – G0010 with diagnosis code V05.3
- Herpes Zoster – The Herpes Zoster vaccine is part of the drug benefit for some Medicare beneficiaries. It is not covered by Part B. The Shingles vaccine and administration fee are considered for coverage under the Medicare Part D benefit.
A professional medical coding company would have experienced AAPC-certified coders who are knowledgeable about the intricacies involved in coding vaccine administration. Physicians that rely on such professional support can expect error-free coding and billing solutions for maximum reimbursement.
Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.