CPT code 90460, 90471 - VFC Immunization administration

CPT CODE and description

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 administere -average fee amount - $20 - $30

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)


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)

Policy Guidelines

If a significantly separately identifiable evaluation and management service is provided at the time of vaccine administration, the evaluation and management service should be reported in addition to the vaccine and toxoid procedure.

Separate reimbursement will be allowed for preventive medicine services 99381-99397.

Separate reimbursement will be allowed for the administration of the vaccines codes (90460-90474).

Vaccines for Children (VFC)

VFC is covered under Section 1928 of the Social Security Act. Implemented on October 1, 1994, it was an “unprecedented approach to improving vaccine availability nationwide by providing vaccines free of charge to VFC-eligible children through public and private providers.”

The goal of VFC is to ensure that no VFC-eligible child contracts a vaccine preventable disease because of his/her parent’s inability to pay for the vaccine or its administration.


Persons eligible for VFC vaccines are between the ages of birth through 18 who meet the following criteria:

* *  Eligible for Medicaid

* *  No insurance

* *  Have health insurance, but it does not offer immunization coverage and they receive their immunizations through a Federally Qualified Health Center

* *  Native American or Alaska native

Providers can obtain an enrollment packet by contacting the Office of Public Health’s (OPH) Immunization Section at (504) 838-5300.

Immunization Guidelines

Applicable Codes: 90460-90749, G0008, G0009, G0010, Q2034-Q2039

Codes 90460 and 90461 must be reported in addition to the vaccine and toxoid codes 90476-90749.

Report codes 90460-90461 only when the physician or qualified health care professional provides faceto-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

Codes 90476-90748 identify the vaccine product only. To report the administration of a vaccine/toxoid, the vaccine product code must be used in addition to the administration code 90460-90474. Modifier 51 should not be reported for the vaccines/toxoids when performed with these administration procedures.

Each immunization given must be filed on a single line of the CMS 1500 claim form, with its specific CPT code.

The -25 modifier must be used with all evaluation and management services except preventive services CPT 99381-99397, when reporting a significant, separately identifiable service in addition to the immunization services.

It is inappropriate to use the unlisted vaccine code CPT 90749 to report immunization administration services.

The invoice from the laboratory or pharmacy the vaccine has been purchased from may be requested for claim review.

ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.


Vaccines For Childern (VFC) Billing Instructions through 18 years of age: Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

* Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the  VFC program. For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

* Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age. Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

Immunization CPT along with E & M codes


Previously announced as a revision to the Rebundling Policy and effective in the first quarter of 2014, UnitedHealthcare will deny Preventive Medicine Evaluation and Management (E/M) services (CPT codes 99381-99397) when reported on the same date of service as an immunization administration service (CPT codes 90460-90461 and 90471-90474) through the CCI Editing Policy. This change aligns with the CMS National Correct Coding Initiative (NCCI) and the American Medical Association Current Procedural Terminology (CPT®)

If modifier 25 is reported with the Preventive Medicine E/M service and the documentation supports that a significant and separately identifiable E/M service was provided on the same date as the administration service, both would be reimbursed. It would not be appropriate to additionally report the Preventive Medicine E/M code for the counseling provided when a vaccine is administered.


Medicaid billing Guide for Immunization Administration

Billing Instructions for 19 years of age and older: 

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure code 90656 (Influenza Virus Vaccine), and another claim line for Procedure code 90471 (Immunization Administration through 19 years of age and older).  For administration (ages 19 and older) of multiple vaccines on the same date, code 90471 should be used for the  first vaccine and 90472 for ANY other vaccines administered on that day. One line will be billed for 90472 indicating the additional number of vaccines administered (insert 1 or 2).

Vaccines For Childern (VFC) Billing Instructions through 18 years of age:  

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code.  Lastly, in field 407-D7 (Product/Service ID), enter the Procedure Code.  Providers may submit up to 4 claim lines with one transaction.  For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age).  For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

** Vaccines for individuals under the age of 19 are provided free of charge by the VFC program. Medicaid WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program.  For reimbursement purposes, the administration of the components of a combination vaccine will continue to be considered as one vaccine administration.

 ** Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor often issues an executive order allowing pharmacies to immunize patients less than 19 years of age.   Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85.  By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

If a clinical staff member performs vaccine administration with or without counseling under the supervision of the provider and, reports the service under the supervising provider, CPT codes 90471 , 90474 must be reported

Vaccine Administration Codes and Reimbursement Rates

The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code(s).

CPT Code          Description                Rate

Use the following codes for vaccine administration to patients of any age when the administration is not accompanied by any face-to-face counseling, or for administration to patients over 18 with or without counseling:

90471 (Including percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccines/toxoid) (do not report in conjunction with 90473) $21.68


+ 90472 Each additional vaccine/toxoid (List separately in addition to 90471, 90473) $12.59


90473 By intranasal or oral route; one vaccine (single or combination vaccine/toxoid) (do not report in conjunction with 90471)  $21.68


+ 90474 Each additional vaccine/toxoid administered by intranasal or oral route (List separately in addition to 90471, 90473) $12.59

Using Vaccine Administration Codes 90471-90474

The immunization administration codes 90471-90474 need to be billed as one (1) line item, and the vaccine product should be billed as a separate line item. In order for an immunization claim to be reimbursed both an administration code and the vaccine product must be billed. If an immunization is the only service rendered, providers may not submit charges for an E&M service.

Adult immunizations are reimbursed at the lower of: billed charges, or the Medicaid fee schedule amount  for each immunization.

Note: Providers are not to bill CPT codes 90471-90474 for children ages 0-18 for whom counseling was given (see section “Using Pediatric Immunization Codes 90460 and 90461” in this manual). CPT Codes 90471-90474 must only be billed for members (ages 19 and older) or members ages 18 and under for whom no counseling was given.

1. Patient/Parent are not counseled on 2 multi-component vaccines. Both are injectables. Patient is 5 years old.

90471 and 90472

Teaching point: Even though the patient meets the age requirement, counseling is not done.


2. Patient/Parent are counseled by the nurse on 2 multiple component vaccines. Both are injectables. Patient is 5 years old.


90471 and 90472

Teaching point: Even though the patient meets the age requirement, vaccine is done by clinical staff (nurse) and therefore
does not meet the OQHCP requirement.


Vaccine Administration Billing Instructions:

• Code the primary vaccine administration code (CPT 90460, 90471, or 90473), the diagnosis code and the EP modifier.

o CPT 90460 should be used to indicate face-to-face counseling was associated with the vaccine administration. CPT 90460 may be billed with more than one unit.

o CPT 90471 and CPT 90473 should be used when there is no face-to-face counseling associated with the vaccine administration. CPT 90471 and CPT 90473 must be billed with a unit value of “1.”

• Code the vaccine product code with the applicable diagnosis code and the EP modifier.

• Code the applicable add-on vaccine administration code (CPT 90472 or 90474) with the appropriate number of units, the diagnosis code and the EP modifier.


o CPT 90472 or CPT 90474 must be coded if more than one non-counseled vaccine was administered.

o CPT 90460 may be used in conjunction with the add-on vaccine administration codes CPT 90472 and CPT 90474 to indicate that first vaccine administered was counseled and the additional vaccines administered were non-counseled.

• Each vaccine administration code should be listed only one time per claim. If multiple vaccine product codes correspond to the same vaccine administration code, the vaccine administration code is listed once with the appropriate number of units indicated.

• The vaccine administration code should be billed with the appropriate charges as outlined in the Department of Community Health Check Services Manual.


Note: This vaccine administration claim example is incorrect for the following reasons:

1. Vaccine administration code CPT 90460 does not precede all vaccines on the claim.

2. Vaccine administration code CPT 90460 is billed with $0.00 charges. The vaccine administration code should be billed with the applicable allowed amount.

3. Vaccine product codes CPT 90744 and 90700 are billed with charges. Charges for vaccine administration should be appended to the vaccine administration code.

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