Understanding Immunizations/ Vaccines the Who, the What and the Codes
Published: October 11, 2024
Author: Andrea McGuire CMPE, CPPM, CEMA, COSC, CPC
Ever since COVID happened, I have heard a lot about immunizations and how some people feel about them. This article isn’t about my feelings on immunizations or vaccines, it is about the who, the what, when and the codes. Even as an adult I didn’t realize that there may be new vaccines (like shingles) or boosters to other vaccines (tetanus) you will need as an adult.
Immunizations and vaccines are developed to help humans fight off diseases and viruses. The Advisory Committee on Immunization Practices (ACIP) develops recommendations for US immunizations, including ages when vaccines should be given, number of doses, time between doses and precautions and contraindications. There is a schedule of immunizations that is put out by the Center for Disease Control (CDC). Even adults should keep up on immunizations and vaccines. The CDC provides a table of vaccines and schedules, along with a catch-up table. This link to the CDC provides immunizations and schedules for providers https://www.cdc.gov/vaccines/hcp/imz-schedules/index.html .
Many states supply immunizations to medical providers who then should supply them for free and only charge the administration fee. Pharmacies also offer immunizations and vaccines, and they will bill the patient’s pharmacy benefits.
Some family practice offices do not understand that Medicare beneficiaries do have access to immunizations and vaccines under their Part D plan (at a pharmacy) and not their Part B (medical) plan. Medicare Part B covers services provided by a physician. Medicare Part D is the pharmacy benefit plan. Medicare Part B as of the date of this article does cover Flu, Pneumonia, Hepatitis B and the Covid 19 vaccine(s).
Coding for Immunization Administrations for Vaccines/Toxoids are in the Medicine section of the CPT book, under codes 90460-90480. Vaccines, Toxoids coding is also found in the Medicine section of the CPT book under codes 90476-90759 and 91300-90759.
Codes 90460-90461 are reported when a physician or other qualified healthcare professional also provides face-to-face counseling to the patient/family during the administration of the vaccine from birth through 18 years of age. When there is no face-to-face counseling to the patient/family and only vaccine administration to a patient over 18 years of age you report 90471-90474.
Codes 90632-90758 are a list of all the immunizations and vaccines ranging from Hepatitis A to Zaire ebolavirus vaccine. When billing these codes make sure that you are also including the National Drug Code (NDC) on your claim. Most clearinghouses and insurance carriers expect the codes to come to them in an 11-digit format which look like: 5-4-2. These codes have a meaning. The first 5 numbers are assigned to the manufacturer or labeler of the drug, the next 4 indicate the strength, dosage form, ingredient and the route of administration, the final two numbers indicate the packaging. If the medication you are administering is short a number, you add a zero “0” in front of the number where it is short a number.
Some of the immunizations are also classified by a HCPCS J codes and some payers will prefer the J code over the 9XXXX codes. You will want to do your research if you are seeing denials for codes that should be paid.
Code 90479 is used for an unlisted vaccine/toxoid.
Codes 90637 and 90638 were added effective July 01,2024 for two new flu vaccines.
Make sure to check payer policies for coverage of immunizations and vaccines to avoid denials.
ABOUT: Andrea McGuire CMPE, CPPM, CEMA, COSC, CPC with Alaska Medical Billing and Coding Solutions LLC
With over 18 years in the medical billing and coding field, I’ve truly found my calling.
The constant challenges and growth opportunities in this field keep me engaged and passionate, making it a career I’d choose over any other.
About NAMAS
NAMAS (National Alliance of Medical Auditing Specialists) is a premier resource for healthcare professionals seeking expert guidance in medical auditing, compliance, and documentation improvement. With a focus on education and certification, NAMAS provides ongoing support through webinars, training sessions, and resources designed to enhance accuracy, compliance, and professional development in the healthcare industry.
