A loss of $262 billion each year…
And yes, all this is because of the denied claims.
Nearly 9% of charges are denied annually each year, which is around $5 million for every hospital, and all of this is because of not using the right CPT codes…For health care providers, it’s not just a random number. Imagine intending to bill for a routine vaccination, using the 90471 CPT Code, but accidentally entering the CPT Code 90461 – a completely different service. This small error will result in denied claims, delayed reimbursements, and unnecessary financial stress.
In this blog, we will cover the CPT codes for vaccine administration so that everything goes smoothly.
What is the 90471 CPT Code?
CPT 90471 is a code that is used to assign a single vaccination to a patient. It is also known as immunization administration. This code can be used for patients of any age and can be used once per day. The code covers flu shots, shingles vaccine, or other immunizations.
CPT Code 90471, at best, can be used for a single vaccination, whereas for more complex procedures, additional codes are required. Whether it’s a routine influenza, you need to use the exact same code for this procedure. Misapplying it will result in denied claims and will cost you financially.
Guidelines for Vaccine Administration
Vaccine Administration During Well-Child Visits
Vaccines are administered during a well-child visit, and to do that, one must follow the ICD-10 (International Classification of Diseases, 10th Edition) guidelines. These are standardized rules for coding and classifying diseases.
According to these rules, Z00.121 or Z00.129 (routine health check for a child over 298 days old) includes immunizations appropriate for the child’s age. Additionally, the Z23 code can also be used if a vaccine is given as part of the routine checkup. ICD-10 requires only one Z23 code per vaccine. Doesn’t matter if it’s a single shot or part of a combination vaccine. To bill a child’s routine checkup correctly, we have to follow the ICD-10 guidelines and use the right codes.
Evaluation and Management Services
This section is all about billing correctly when a patient gets both an evaluation and a vaccine on the same day. In this situation, modifier-25 should be added to the evaluation code. This modifier indicates that the evaluation and management service is separate from the vaccine administration.
For Example:
If a patient gets an evaluation for diabetes and also gets a vaccine (Flu shot) on the same day. The doctor will use code 99213-25 for the visit with diagnosis code E11.9 for diabetes, and also the CPT code for the vaccine.
Adding National Drug Codes (NDC) to Claims
If you are submitting claims, Medicaid and some private insurance companies may also require the National Drug Code (NDC) for each vaccine product. This can be a bit confusing because vaccines usually have a 10-digit NDC, but for HIPAA compliance, you need to change it to an 11-digit format.
The common format for submitting an NDC is a number that, if hyphenated, would appear in a 5-4-2 format.
| 10-Digit NDC | 11-Digit HIPAA Format NDC |
| 12345-6789-10 | 12345-0678-9 |
| 98765-4321-00 | 98765-0432-10 |
90471 CPT Code vs 90472 CPT Code Description – What’s the Difference?
As we discussed above, the procedure Code 90471 is used for a single vaccine. CPT 90472 is used to administer additional vaccinations to the patient in the same visit. It applies to each additional vaccine/toxoid component only after the first one has already been billed using the right administration code (like CPT 90471)
This code is most commonly used in pediatric clinics where multiple shots are given on every visit.
| Code | CPT Code Description | When to Use |
| CPT 90471 | Initial Vaccine Administration (via Injection) | Use for a single injectable vaccine/toxoid during a visit. |
| CPT 90472 | Each Additional vaccine/toxoid (Injection, Same Visit) | Use for each additional injectable vaccine after 90471 is billed. |
| CPT 90461/90460 | For Pediatric Vaccines with counseling (Under 18) | Used when counseling is provided during vaccine administration to children |
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Related CPT Codes to Know
| Code | CPT Code Description | When to Use |
| 90686 CPT Code | Influenza Virus Vaccine, Quadrivalent | Use for seasonal flu shots (ages 3+). Add flu vaccine NDC (11 digits) if required by the payer. |
| CPT Code 90714 | Tetanus and Diphtheria Toxoids (Td) | Adult Td vaccine (without pertussis). Often used for booster immunization. |
| 90715 | Tetanus, Diphtheria, and Pertussis (Tdap) | Use (90715 CPT Code Description) when billing for the Tdap vaccine (includes pertussis). Common for adolescents and adults. |
| 90461 CPT Code | Additional Vaccine Component (each) | Use with 90460 to bill for each extra antigen in combination vaccines for patients under 18. |
| CPT Code 90710 | MMR-V (Measles, Mumps, Rubella, Varicella) | Use for a combination vaccine covering all four diseases in a single dose. |
| CPT Code for Shingles Vaccine | Varies (e.g., 90750 for Shingrix) | For shingles vaccination, typically Shingrix. Always include the NDC (11-digit format). |
Common Billing Mistakes to Avoid with Procedure Code 90471
When it comes to medical billing, even a small mistake can cause big problems. Here are some things to help you avoid any big financial losses and stress.
1. Not Using 90472 When More Than One Vaccine Is Given
CPT 90471 is for one vaccine. Now, if a patient gets multiple vaccines on the same visit, you have to use 90472 for each additional vaccine. A minor mistake, like using 90471 CPT Code, will result in underpayments and financial loss.
2. Forgetting to Attach the Vaccine Product Code (e.g., 90686 CPT Code)
Each vaccine has its own CPT code, like 90686 for the flu vaccine. If you forget to add the 90686 to the bill, then there will be no claims from the insurance company. You will have to pay for everything yourself. It will leave you to cover all the costs by yourself.
3. Confusing CPT Code 90461 vs CPT 90471
One of the biggest mistakes is getting 90461 mixed up with 90471. 90461 CPT Code is used when counseling is provided along with the vaccine. It is mostly used for pediatric patients under 18. While CPT Code 90471 is used for vaccines administered only a single time. Using the right code is necessary to get paid.
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Understanding the ins and outs of different codes in medical billing ensures faster claim approvals, higher accuracy, and fewer financial hiccups for your healthcare organizations. However, the difficulties of medical billing need professional support and guidance.
Providers Care Billing LLC is a USA-based company in Illinois, USA We are experts in offering comprehensive coding services and medical billing. Our team ensures efficient, smooth, and compliant processes if you need help with lab draws, venipuncture claims, or any other medical billing issues.
