The Summit Provider and Access Workgroup surveyed partners and compiled the following Top Questions associated with coding and billing for adult vaccines. Click on each question to view the helpful guidance that has been developed for each of these questions.
CODING1. What ICD-10 diagnosis code do I use when immunizing?
Z23 is the ICD-10 code that identifies an encounter for an immunization. If the immunization is related to exposure (for example, Td vaccine administered as a part of wound care), the ICD-10 code describing the wound should be used as the primary diagnosis code for the vaccine and Z23 should be used as the secondary code.
Billing for vaccine administration:
Proper Current Procedural Technology (CPT) codes for the vaccines administered, as well as for the vaccine administration service, must be used on claim forms. The vaccine CPT codes can be found on the CDC website.
An initial vaccine administration code must be reported, regardless of vaccine administration method.
- 90460 – Used for patients 18 years and younger, and when counseling is provided, i.e. when the physician or qualified health care professional provides face-to-face counseling during administration of the vaccine.
- 90471 – Used for any immunization administration (for vaccines that are not orally or nasally administered) without counseling.
- 90473 – Used for vaccines that are administered orally or nasally and when additional counselling is not provided.
These initial administration codes (CPT 90460, 90471, and 90473) cannot be billed together on the same date of service and cannot be billed more than once per day.
When one of these initial vaccine administration codes is billed, all additional vaccines/toxoid components administered on that day should be reported with the appropriate add-on code (i.e. 90461, 90472 or 90474). Because counseling is attached to the pediatric codes (90460 and 90461), if the vaccine is not a single antigen vaccine, additional vaccine antigens/toxoids can be coded using 90461 for each additional antigen.
However, since the 90471 – 90474 codes do not include counseling and can be used both for adult and pediatric patients, they are billed per injection. 90472 would be used only if a second injection was given at the same visit.
EXAMPLE: Coding with a Multiple Antigen Vaccine
Patient Age: 18 years or less
Coding: Bill first with 90460, then two more times using 90461
Patient Age: 19 years or older
Coding: Bill with 90471 only (If another vaccine is given at the same visit, code the administration fee for the second injection with 90472.)
When billing for multiple vaccine administrations, you can either report administration add-on codes per line or report as multiple units on one line.
Billing for vaccines:
For coding purposes, a vaccine’s National Drug Code (NDC) does not need to be linked to the CPT codes. However, some payers may require that the NDC to be entered on a separate segment of the claim form. United Healthcare seems to be enforcing a policy that will require NDCs for immunizations. If required, then the NDC on the vial/unit of use should be submitted. You can find NDC codes for vaccines on the CDC website.
With influenza vaccines, the NDCs change each year since the vaccine strains change almost every year.
Effective January 2017, the American Medical Association published an update to their CPT coding for influenza vaccines. First, they have added separate codes to better distinguish different influenza vaccines, and second, eight previously-existing influenza vaccine codes are now reported by dosage, rather than patient age. CDC also has a website which lists the different CPT codes for different influenza vaccine formulations.
Some payers (for example, TriCARE and some Medicaid plans) require that the vaccine’s NDC be included on the claim form in addition to the vaccine’s CPT code. It is up to the payer as to whether the unit of use or carton NDC should be used. Payers who require the use of an NDC code have been encouraged to accept both NDC codes.
Please also see the answer to Question #2 above. CDC maintains a list of vaccine-specific NDC codes.
Q codes are used to identify services that would not be given a CPT-4 (i.e., CPT, Fourth Edition) code, such as drugs, biologicals, and other types of medical equipment or services, and are not identified by national Level II codes, but for which codes are needed for claims processing purposes.
Generally, for adult immunizations, Q codes are available for the trivalent preservative-containing influenza vaccines. Other vaccine formulations (for example, cell culture, high-dose, adjuvanted, and recombinant influenza vaccines) should be coded using the CPT nomenclature.
BILLING5. Can I give vaccines on the same day as an evaluation and management (E/M) visit or a preventive visit, and how do I bill properly for the administrative fee and the cost of the vaccines?
Yes, you can give and bill for vaccines on the same day as an E/M visit or a preventive visit. The appropriate CPT vaccine administration code should be submitted in addition to the appropriate CPT or Healthcare Common Procedure Coding System (HCPCS) vaccine product code. These codes should be linked to the ICD-10 code to support the medical necessity of the vaccine administration services.
When an E/M service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier 25 may be appended to the code for the E/M service to indicate that this service was significant and separately identifiable from the physician’s work of the vaccine administration.
If there is no E/M or preventive visit coded on the claim, or if only immunizations are given at the visit, then a modifier 25 is not required.
When a preventive medicine service code (99381-99395) is provided on the same day as a prophylactic immunization, append modifier 25 to the preventive medicine service codes when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474).
ICD-10 requires only one code (Z23 – Encounter for immunization) per vaccination, regardless if the vaccine is a single antigen or combination of antigens. Link both the CPT vaccine product code and the CPT vaccine administration code to Z23. Remember that the Z23 code is also reported in addition to any health exam codes.
Yes, if a significant, separately identifiable E/M service is performed, the appropriate E/M service code should be reported in addition to the vaccine administration code. See also Question #5 on the use of modifier 25.
Report the appropriate CPT “add-on” administration code for reach additional vaccine given on the same date of service in addition to the appropriate vaccine product codes (CPT or HCPCS) for the additional vaccines. See also Question #2 above.
Although the general discussion of vaccines is part of age-appropriate preventive medicine counseling, the actual administration of the vaccine and the vaccine product should be billed separately.
If the patient is aged 18 years or younger, CPT codes that include counseling by a physician or other qualified health care professional may be reported if the physician or qualified health care professional provides face-to-face counseling during the visit in which vaccines are administered. If the patient is older than 18 years, it may be appropriate to bill an E/M visit code in addition to the vaccine administration code if the counseling by the physician or qualified health care provider exceeds the usual services included in vaccine administration.
Each payer has a time frame in which claims must be submitted. Claims submitted after this time has expired will be denied. Claims must always identify the date a service was actually provided.
If you are still within the claim submission time frame, you should be able to bill but details will vary. For influenza, Medicare Part B does not formally publish its payment rates for influenza vaccines until its release of the October quarterly update to the Part B Drug Fee Schedule. The updated rates are applicable to immunizations administered after August 1. Each Medicare Administrative Contractor has its own process for adjusting the payments for the vaccines administered prior to the update. As an alternative, health care providers can hold claims until after the October 1 updates are implemented. The process for obtaining updated payments from Medicare Advantage plans, Medicaid and private payers will vary (For more information, see The Changing Payment Landscape of Current CMS Payment Models Foreshadows Future Plans.)
CMS10. Does Medicare cover vaccine administration services? What are the differences between Part B and Part D in terms of which vaccines they cover?
Yes, Medicare covers vaccines and vaccine administration fees. The influenza and pneumococcal vaccines, hepatitis B vaccine for persons with a high-risk condition, and Td vaccine for wound management are covered under Medicare Part B or Medicare Advantage plans. The administration fees for these vaccines are also paid out of Medicare Part B or Medicare Advantage plans. All other vaccines, including zoster vaccine and Td and Tdap vaccines for prophylaxis, and administration fees for these vaccines, are covered by Medicare Part D plans.
When entering the units associated with the CPT code, one (1) unit is entered for both the vaccine product and for the vaccine administration. If two vaccines area administered, then two units would be billed.
INSURANCE12. If insurance has denied coverage, what resources are available to help me with an appeal letter?
All vaccine manufacturers and some medical associations have resources on coding and billing for providers. The provider should contact the individual manufacturer’s reimbursement support services. Sometimes a formal appeal is not required if the manufacturer’s support service can contact the payer and work through the issue.
All Health Insurance Marketplace plans and most other private insurance plans must cover the following list of vaccines without charging a copayment or coinsurance when provided by an in-network provider. This is true even for patients who have not met a yearly deductible. Doses, recommended ages, and recommended populations for these vaccines vary:
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus
- Measles, Mumps, Rubella
- Tetanus, Diphtheria, Pertussis
The key phrase is “in-network provider.” Health plans vary as to who they consider in-network. Always check with your health plan to see which providers are recognized as in-network. This relates to retail pharmacies, too. Some health plans will recognize pharmacies as in-network, while some plans will not.
Medicaid coverage for vaccines vary by state.
REFERRAL14. I don’t stock some or all vaccines. Where can I send my patient?
HealthMap Vaccine Finder provides an interactive locator to identify the closest provider that will have the vaccine of interest. The locator covers all ACIP-recommended vaccines. In addition, reach out to other providers within your immunization neighborhood (such as pharmacies) to determine which vaccines they stock and administer. Patients should also be sure to check with their insurance carriers regarding in-network locations for receiving vaccinations.