Flu season is upon us, so now is a great time for “Spotlight on CPT” to review information on the proper coding for vaccinations. Every year this topic presents issues, even for seasoned coding professionals. So, let’s review.
We begin by reminding coding professionals who assign CPT codes for vaccinations that two codes will be needed in order to capture the entirety of the procedure; one code is for the administration of the vaccine (the actual injection itself), and the second code is for the vaccine or toxoid that is being given. We will begin by addressing the administration codes first.
CPT codes for the administration of a vaccine are broken down into three distinct groups. The first group of codes (90460-90461) require that the physician or qualified healthcare professional provide counseling regarding the component(s) of the vaccine to the patient. These codes may be assigned for the administration of vaccine to anyone through the age of 18 and by any route. The second group of codes (90471-90474) are to be used when no counseling is performed. These codes are distinguished by the route of administration:
Once the appropriate administration code has been chosen, the coding professional will need to determine the appropriate vaccine or toxoid code that should also be assigned. In this coding step, it is important that the precise code for the vaccine/toxoid is assigned. Different CPT codes exist for vaccines that have variations in chemical formulation (influenza vaccines for example), dosage (hepatitis A-adult vs. pediatric dosage for example), or route of administration (rabies-intradermal vs. intramuscular for example). CPT codes for vaccine/toxoid codes may also differentiate if there is a schedule difference for vaccine products of the same vaccine type. This means that either the timing of the administration is different or the number of doses is different.
When assigning the vaccine/toxoid code, coding professionals should be aware that there are some combination codes available. Remember, that in CPT, it is inappropriate to code for the individual components of a vaccine if a combination code exists. For example, if an adult patient was to receive an intramuscular Hib-HepB vaccine, the appropriate code is 90748 and not 90739 and 90647.
If a coding professional encounters a vaccine that does not have a specific CPT code, an unlisted code (90479) should be assigned. It is also noteworthy that the coding for immune globulins is not part of any of the previously mentioned categories of codes. Product codes for the immune globulins are in the range of 90281-90399, while the administration codes fall under 96365-96375.
In the CPT Manual, the symbol ~ signifies vaccine product codes which have yet to be approved by the Food and Drug Administration (FDA). Once the vaccine product is approved, the symbol will be removed.
Let’s look at two specific scenarios in order to apply the concepts noted above. A 60 year-old female goes to a local pharmacy to get a Shingrix vaccine. The pharmacist administers the vaccine intramuscularly in the left shoulder and provides information on possible side effects. The CPT codes to assign are 90471 for the administration and 90750 for the Zoster vaccine.
A 48 year-old male goes to a local pharmacy to get his second in the series of Pfizer vaccines against COVID-19. By utilizing the Appendix Q table, we can see that the administration code for this vaccine will be 0002A for the second dose of the Pfizer COVID vaccine, and 91300 is the code that should be assigned for the vaccine itself.
Now, light has been shed on coding for vaccinations.
We begin by reminding coding professionals who assign CPT codes for vaccinations that two codes will be needed in order to capture the entirety of the procedure; one code is for the administration of the vaccine (the actual injection itself), and the second code is for the vaccine or toxoid that is being given. We will begin by addressing the administration codes first.
CPT codes for the administration of a vaccine are broken down into three distinct groups. The first group of codes (90460-90461) require that the physician or qualified healthcare professional provide counseling regarding the component(s) of the vaccine to the patient. These codes may be assigned for the administration of vaccine to anyone through the age of 18 and by any route. The second group of codes (90471-90474) are to be used when no counseling is performed. These codes are distinguished by the route of administration:
- Percutaneous injection
- Intradermal injection
- Subcutaneous injection
- Intramuscular injection
- Via intranasal or oral route
Once the appropriate administration code has been chosen, the coding professional will need to determine the appropriate vaccine or toxoid code that should also be assigned. In this coding step, it is important that the precise code for the vaccine/toxoid is assigned. Different CPT codes exist for vaccines that have variations in chemical formulation (influenza vaccines for example), dosage (hepatitis A-adult vs. pediatric dosage for example), or route of administration (rabies-intradermal vs. intramuscular for example). CPT codes for vaccine/toxoid codes may also differentiate if there is a schedule difference for vaccine products of the same vaccine type. This means that either the timing of the administration is different or the number of doses is different.
When assigning the vaccine/toxoid code, coding professionals should be aware that there are some combination codes available. Remember, that in CPT, it is inappropriate to code for the individual components of a vaccine if a combination code exists. For example, if an adult patient was to receive an intramuscular Hib-HepB vaccine, the appropriate code is 90748 and not 90739 and 90647.
If a coding professional encounters a vaccine that does not have a specific CPT code, an unlisted code (90479) should be assigned. It is also noteworthy that the coding for immune globulins is not part of any of the previously mentioned categories of codes. Product codes for the immune globulins are in the range of 90281-90399, while the administration codes fall under 96365-96375.
In the CPT Manual, the symbol ~ signifies vaccine product codes which have yet to be approved by the Food and Drug Administration (FDA). Once the vaccine product is approved, the symbol will be removed.
Let’s look at two specific scenarios in order to apply the concepts noted above. A 60 year-old female goes to a local pharmacy to get a Shingrix vaccine. The pharmacist administers the vaccine intramuscularly in the left shoulder and provides information on possible side effects. The CPT codes to assign are 90471 for the administration and 90750 for the Zoster vaccine.
A 48 year-old male goes to a local pharmacy to get his second in the series of Pfizer vaccines against COVID-19. By utilizing the Appendix Q table, we can see that the administration code for this vaccine will be 0002A for the second dose of the Pfizer COVID vaccine, and 91300 is the code that should be assigned for the vaccine itself.
Now, light has been shed on coding for vaccinations.
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About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer. Dianna has held many positions in HIM and is now an independent coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee. She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
