Basics for G codes & CPT code 90471, 90472, 90473, +90474

For Medicare, the use G codes is very common for billing specific procedures. For example, the Vaccine administration codes used for flu, is reported with G code G0008. Similarly there are many G codes used for Medicare patients.Also, there are diagnosis codes like Z23 used for coding vaccination encounters. There are also more procedures codes used along with G codes for vaccination like CPT code 90471, +90472, 90473, +90474 which we will checkout one by one. 

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Description of HCPCS code G0008, G0009, G0010 & CPT code 90471, 90472, 90473, +90474

HCPCS Codes G0008 and G0009 should be used to report administration of the vaccines described in the code descriptors for Medicare patients. For non-Medicare patients, it could be appropriate to report a code from CPT code range 90460–90474 for the administration of a vaccine. Both sets of codes identify the administration of these vaccines, not the vaccine product itself. It would be appropriate to report the CPT code that most accurately describes the vaccine administered in addition to the HCPCS G code or CPT code for the vaccine administration.

When billing influenza, influenza H1N1, pneumonia or hepatitis B, the Centers for Medicare and Medicaid (CMS) require physicians to report HCPCS administration codes rather than CPT administration codes. The HCPCS administration codes and the vaccine codes have a one-to-one relationship and are always paired together. Rules for reporting initial or subsequent vaccines do not apply. The HCPCS administration codes and the vaccines they are paired with are listed below:

• G0008 for the flu vaccine ; Administration of influenza virus vaccine
• G0009 for the pneumonia vaccine ; Administration of pneumococcal vaccine
• G0010 for the hepatitis B vaccine ; Administration of hepatitis B vaccine
• G9141 (deleted)– Flu H1N1

For vaccines given the same day as a G-Code vaccine, use 90471. For example, if a patient receives a flu shot and tetanus shot, you would bill G0008 for the flu vaccine and 90471 for the tetanus vaccine; also add modifier 59 (distinct procedural service) to the G code.

A physician, nurse, or medical assistant administers an injectable (percutaneous, intradermal, subcutaneous, or intramuscular) immunization to the patient. It may be a single vaccine or a combination vaccine/toxoid in one immunization administration (e.g., diphtheria, pertussis, and tetanus toxoids are in a single DPT immunization). CPT code 90471 is reported for one vaccine and CPT code 90472 for each additional vaccine (single or combination vaccine/toxoid).

Be sure to append modifier 25 to a separate E/M service provided on the same day as the vaccine, under CPT guidelines.

For Commercial Insurrance payers you can used the below procedure codes

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

+90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

+90474 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use

90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use

Do not get confuse with CPT code 96372, since CPT code 90471 is used for vaccines and CPT code 96372 is used for  drugs.

Supply codes used with above procedures.

SC058 syringe w-needle, OSHA compliant (SafetyGlide)
SG021 bandage, strip 0.75in x 3in (Bandaid)
SK012 CDC information sheet

NCCI edits with CPT code 90471 and 90472

Below are the NCCI edits between different procedure codes with CPT code 90471 and 90472, do check the list before assigning bypass modifier like 59 or X- modifier.

Points to remember

• 90471 is used  for a single vaccine or if given the same day as a G-Code vaccine. If you use additional G-codes be sure to add modifier 59
• 90472 If you administer more than one vaccine use this code with modifier 59 (in addition to the single vaccine)
• 90473 for Oral or intranasal route
• Do not report 90471 in conjunction with 90473
• When the Patient visit purpose is only to take vaccination, then Z23 is the only diagnosis code that should appear on the claim.
• Check the patient’s age when reporting a code for the vaccine administration.

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Indications and Limitations of Coverage and/or Medical Necessity