Coding for 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.

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.

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. About PDFs.).

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

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

Alternatively, physicians may contract with eDispense Vaccine Manager when providing and administering Part D vaccines and bill the Part D plan using a web-based portal that verifies patient eligibility, vaccine coverage, and allowable and out-of-pocket costs. Physicians should note that enrolling in this program requires that the physician accept the allowed amount as full payment for the vaccine and its administration. This service is not endorsed or recommended by the AAFP. This specific product information is provided for member consideration as this appears to be the only such product currently available.