CPT code 90471, 90472 : Vaccine Administration Coding tips

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. 

CPT Code 90471-9074 is used when the drug is administrated by a medical assistant or nurse and the patient does not see the physician at all. This code would also be used for any patient 18 years of age or older regardless if physician is present and does face-to-face counseling.

CPT code 90471, 90472 : Vaccine Administration Coding tips

Read also: When to use the Hydration CPT codes in ED

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 9046090474 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 90471For 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.

Major Code/Column 1Minor Code/Column 2Modifier/Policy Indicator
904710591T1-Allowed
904710592T1-Allowed
904710593T1-Allowed
90471365910-Not allowed
90471365920-Not allowed
90471904730-Not allowed
90471907820-Not allowed
90471907840-Not allowed
90471961601-Allowed
90471961601-Allowed
90471961611-Allowed
90471961611-Allowed
90471965230-Not allowed
90471992011-Allowed
90471992011-Allowed
90471992021-Allowed
90471992021-Allowed
90471992031-Allowed
90471992031-Allowed
90471992041-Allowed
90471992041-Allowed
90471992051-Allowed
90471992051-Allowed
90471992110-Not allowed
90471992110-Not allowed
90471992111-Allowed
90471992121-Allowed
90471992121-Allowed
90471992131-Allowed
90471992131-Allowed
90471992141-Allowed
90471992141-Allowed
90471992151-Allowed
90471992151-Allowed
90471992411-Allowed
90471992421-Allowed
90471992431-Allowed
90471992441-Allowed
90471992451-Allowed
90471992519-Not applicable
90471992529-Not applicable
90471992539-Not applicable
90471992549-Not applicable
90471992559-Not applicable
90471992811-Allowed
90471992811-Allowed
90471992821-Allowed
90471992821-Allowed
90471992831-Allowed
90471992831-Allowed
90471992841-Allowed
90471992841-Allowed
90471992851-Allowed
90471992851-Allowed
90471993811-Allowed
90471993821-Allowed
90471993831-Allowed
90471993841-Allowed
90471993851-Allowed
90471993861-Allowed
90471993871-Allowed
90471993911-Allowed
90471993921-Allowed
90471993931-Allowed
90471993941-Allowed
90471993951-Allowed
90471993961-Allowed
90471993971-Allowed
90471994011-Allowed
90471994021-Allowed
90471994031-Allowed
90471994041-Allowed
90471994061-Allowed
90471994061-Allowed
90471994071-Allowed
90471994071-Allowed
90471994081-Allowed
90471994091-Allowed
90471994111-Allowed
90471994121-Allowed
90471994201-Allowed
90471994831-Allowed
90471994831-Allowed
90471994971-Allowed
90471994971-Allowed
90471994979-Not applicable
90471G00081-Allowed
90471G00091-Allowed
90471G00101-Allowed
90471G04429-Not applicable
90471G04421-Allowed
90471G04439-Not applicable
90471G04431-Allowed
90471G04449-Not applicable
90471G04441-Allowed
90471G04451-Allowed
90471G04459-Not applicable
90471G04631-Allowed
90471G05051-Allowed

Major Code/Column 1Minor Code/Column 2Modifier/Policy Indicator
904720591T1-Allowed
904720592T1-Allowed
904720593T1-Allowed
90472365910-Not allowed
90472365920-Not allowed
90472961601-Allowed
90472961601-Allowed
90472961611-Allowed
90472961611-Allowed
90472965230-Not allowed
90472992011-Allowed
90472992011-Allowed
90472992021-Allowed
90472992021-Allowed
90472992031-Allowed
90472992031-Allowed
90472992041-Allowed
90472992041-Allowed
90472992051-Allowed
90472992051-Allowed
90472992110-Not allowed
90472992110-Not allowed
90472992111-Allowed
90472992121-Allowed
90472992121-Allowed
90472992131-Allowed
90472992131-Allowed
90472992141-Allowed
90472992141-Allowed
90472992151-Allowed
90472992151-Allowed
90472992411-Allowed
90472992421-Allowed
90472992431-Allowed
90472992441-Allowed
90472992451-Allowed
90472992519-Not applicable
90472992529-Not applicable
90472992539-Not applicable
90472992549-Not applicable
90472992559-Not applicable
90472992811-Allowed
90472992811-Allowed
90472992821-Allowed
90472992821-Allowed
90472992831-Allowed
90472992831-Allowed
90472992841-Allowed
90472992841-Allowed
90472992851-Allowed
90472992851-Allowed
90472993811-Allowed
90472993821-Allowed
90472993831-Allowed
90472993841-Allowed
90472993851-Allowed
90472993861-Allowed
90472993871-Allowed
90472993911-Allowed
90472993921-Allowed
90472993931-Allowed
90472993941-Allowed
90472993951-Allowed
90472993961-Allowed
90472993971-Allowed
90472994011-Allowed
90472994021-Allowed
90472994031-Allowed
90472994041-Allowed
90472994061-Allowed
90472994061-Allowed
90472994071-Allowed
90472994071-Allowed
90472994081-Allowed
90472994091-Allowed
90472994111-Allowed
90472994121-Allowed
90472994201-Allowed
90472994831-Allowed
90472994831-Allowed
90472994979-Not applicable
90472994971-Allowed
90472994971-Allowed
90472G04421-Allowed
90472G04429-Not applicable
90472G04431-Allowed
90472G04439-Not applicable
90472G04441-Allowed
90472G04449-Not applicable
90472G04451-Allowed
90472G04459-Not applicable
90472G04631-Allowed
90472G05051-Allowed

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.

Read also: Coding guide for Nasal Hemorrhage CPT codes

Indications and Limitations of Coverage and/or Medical Necessity

Medicare Part B provides preventive coverage only for certain vaccines. These include:

  • Influenza: once per flu season (codes 90630, 90653-90657, 90660-90662, 90672-90674, 90685-90688, 90756, Q2034-Q2039, 90682)
        • Claim should contain HCPCS G0008 and ICD-10 Z23
        • Effective for dates of service 8/01/2017 thru 12/31/2017 claims for Flucelvax Quadrivalent influenza vaccine should be billed utilizing HCPCS Q2039 (Influenza virus vaccine, not otherwise specified).
        • NOTE– Claims billed for dates of service prior to 12/31/2017, if submitted on or after 01/01/2018, must bill HCPCS Q2039 for the claim to process correctly.
  • Pneumococcal: An initial pneumococcal vaccine to Medicare beneficiaries who have never received the vaccine under Medicare Part B; and a different, second pneumococcal vaccine 1 year after the first vaccine was administered (codes 90670 and 90732)
    • Claim should contain HCPCS G0009 and ICD-10 Z23
    • Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit (use seasonal influenza virus and pneumococcal vaccine codes
    • Claim should contain HCPCS G0008 AND G0009 AND ICD-10 Z23
  • Hepatitis B: for persons at intermediate- to high-risk only (codes 90739- 90740, 90743-90744, 90746-90747). People who are considered high or medium risk for hepatitis B are:
  1. Those with End-Stage Renal Disease (ESRD) also known as kidney failure
  2. Hemophiliacs
  3. Clients and staff at institutions for the developmentally disabled
  4. Those who live in the same household as a hepatitis B carrier 
  5. Homosexual men
  6. Illicit drug users
  7. Health care professionals who have frequent contact with blood or other body fluids during routine work

•Claim should contain HCPCS G0010 and ICD-10 Z23

  • Other immunizations are covered under Medicare Part B only if they are directly related to the treatment of an injury or direct exposure:
    • Rabies (90675-90676)
    • Claim should contain Z20.3 and Z29.14
  • Tetanus (90702 and 90714)
  • Claims should be coded with the diagnosis appropriate to the injury- see the Covered ICD-10 Codes section of this article

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