CPT Code for Vaccine Administration
When vaccines are administered during a well-child visit, the ICD-10 recommendations specify that codes Z00.121 or Z00.129 (regular health check for kids over 298 days old) should include immunizations appropriate for the patient’s age. The secondary code Z23 may be used if the vaccine is administered as part of a preventative health care service, such as a well-child visit. ICD-10 Classification of Combination Vaccines
ICD-10 mandates only one code (Z23) for each vaccine, whether single or many. Report all vaccination diagnoses using Z23.
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 concurrently with a prophylactic immunization, modifier -25 may be added to the code for the evaluation and management service to indicate that it was significant and distinct from the physician’s work of vaccine counseling/administration.
Adding National Drug Codes (NDC) to Claims
Medicaid plans and private payers may require you to provide the National Drug Code (NDC) for each vaccination product on your claim line. This can be perplexing if the product is labeled with a 10-digit NDC, while HIPAA demands 11-digit NDCs. To properly report the NDC in the HIPPA format, the NDC may need to be translated.
The most often used format for providing an NDC is a number that, when hyphenated, appears as 5-4-2. Certain pharmaceutical medicines are labeled using the 4-4-2, 5-3-2, or 5-4-1 forms. To convert these codes to the 11-digit format, zero is substituted for the first digit in the product code, resulting in the 5-4-2 format.
Here are some examples of how to generate this format by adding a zero:
Vaccine administration coding
Report codes 90460 and 90461 only when a physician or other competent health care professional counsels the patient/family face-to-face during the vaccine administration. Report codes 90471-90474 for vaccine administration that is not accompanied by face-to-face counseling of the patient/family or for vaccine administration to patients over the age of 18 years.
Code 90460 is recorded once for each vaccination or toxoid provided by any method. Counseling for the first vaccination component is included in the reporting of code 90460. Additionally, code 90461 is used to report counseling for each extra component of any combination vaccination or toxoid.
- 90460 Through 18 years via any route with counseling by physician or other qualified health care professional; first vaccine/toxoid component
- 90461 Through 18 years via any route, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component
- 90471 (including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid)
- 90472 (including percutaneous, subcutaneous, intradermal, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid)
Administration Coding Example
A little girl of 11 years presents for a preventive visit (99393). Additionally, the physician counsels the youngster and her mother on the dangers and benefits of HPV (90649) and Tdap (90715). The physician takes notes during the session. Consent is obtained from the mother for the administration of these vaccinations. A nurse prepares and delivers each vaccine, completes chart documentation and vaccine registry entries, and ensures no adverse response occurs immediately.
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)
Medicare Part B and Part D Vaccine Coverage
Medicare Part B covers preventative treatment for only a limited number of immunizations. These include the following:
- Influenza: once during the influenza season (codes 90630, 90653, 90656, 90662, 90673-74, 90682, 90685-88, 90756, Q2035, Q2037, Q2039)
- Pneumococcal infection: (codes 90670, 90732, once per lifetime with a high-risk booster after 5 years)
- Hepatitis B: for individuals at a moderate-to-high risk (codes 90739- 90740, 90743-90744, 90746-90747)
The following HCPCS codes are used to record administration services for certain preventative vaccinations to Medicare:
- G0008 Influenza virus vaccine administration
- G0009 pneumococcal vaccine administration
- G0010 Hepatitis B vaccine administration
The diagnosis code for these preventative vaccinations is as follows:
- Z23 Immunization encounter
- Other vaccinations are reimbursed by Medicare Part B only if they are necessary for the treatment of an injury or direct exposure (such as anti-rabies treatment, tetanus antitoxin, or booster vaccine, botulin antitoxin, antivenin, or immune globulin)
Other vaccines administered as part of a preventive service may be reimbursed by a patient’s Part D coverage.