Coding for Vaccine Administration

Vaccine Coding

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:

10-DIGIT NDC	11-DIGIT NDC
4444-4444-22	04444-4444-22
55555-333-22	55555-0333-22
55555-4444-1	55555-4444-01

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.

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)