Immunizations

CPT Coding of Vaccines and Administration

Physicians may report the administration of vaccines using codes 90465-90474. The vaccine product is separately reportable using codes 90476-90749.

Administration codes 90465-90468 are reported only when the physician provides face-to-face counseling to a patient/family during the administration of a vaccine to a patient younger than 8 years of age. For administration of any vaccine that is not accompanied by face-to-face physician counseling to the patient/family or provided to a patient 8 years of age or older, report codes 90471-90474.

When reporting multiple vaccine administrations on the same date, note that only one first order administration code should be reported. For instance, when reporting two vaccines administered by injection to a child under 8 years of age with physician counseling, code 90465 is reported for the first vaccine administration and code 90466 is reported for the additional vaccine administration. Were the second vaccine administration by oral or intranasal route, code 90468 could be reported in addition to code 90465.

Vaccines Covered as Medicare Preventive Services

Medicare Part B provides preventive coverage only for certain vaccines. These are the influenza virus vaccine, pneumococcal vaccine, and hepatitis B vaccine. For information on the coverage criteria for these vaccines, see the Guide to Medicare Preventive Services (PDF file: 196 Pages/1590 KB. More information on using PDF files.).

In order to indicate the administration of a vaccine covered as a preventive service, physicians should report these services using HCPCS G codes G0008-G0010.

Vaccines Covered Under Part D Medicare

In 2007, Medicare Part B will cover the administration of vaccines that are covered under Part D of Medicare. An example of this would be the vaccine for shingles (CPT code 90736). A new G code (G0377) has been created for the administration of Part D vaccines and payment for G0377 will be crosswalked to CPT code 90471 for one year. When a physician administers a Part D vaccine, the physician should use G0377 to bill the local carrier for the administration of the vaccine. Payment to the physician will be on an assigned basis only. Normal beneficiary deductible and coinsurance requirements apply to the administration.

Payment for Part D covered vaccines is made solely by the participating Prescription Drug Plan. Medicare Part B will not pay for the vaccine itself. When providing a Part D covered vaccine to a Medicare patient, the physician should charge the patient for the vaccine itself. To facilitate the patient's reimbursement for the vaccine by his or her Part D plan, the physician's office should complete a CMS-1500 form for the vaccine and give it to the patient to file as an unassigned, out-of-network claim.

E & M Services Provided on the Same Date

If a significant, separately identifiable Evaluation and Management service is performed on the same date as an immunization service, the appropriate E & M code should be reported in addition to the vaccine and toxoid administration codes. Report a -25 modifier with the E & M code to indicate that the service performed was significant and separately identifiable from the work of administering the immunization.