Accurate Coding for Vaccines | 90471, 90472 and more| - Healthcare Revenue Cycle Management Solutions | Pararev (2024)

From flu to tetanus and now COVID-19, vaccines are among the most common outpatient procedures providers administer on a day-to-day basis. But they can also be complex to code and bill, and undetected mistakes can result in continual underpayment for services rendered.

What makes vaccines so tricky? In most instances, coders must consider a range of factors to ensure the procedure is properly coded, and it can be easy to overlook specific details or nuances. This is especially true if multiple injections are given to a single patient during one encounter.

Some of the key variables associated with vaccine coding include:

• Patient age
• Insurance
• Route of administration
• Total number of vaccines given in the same encounter
• Physician counseling
• State vaccines programs

General Vaccine Information

Q-Codes

Vaccine codes are published on a semi-annual basis, typically July 1 and January 1, by the American Medical Association (AMA). Current Procedural Terminology (CPT®) vaccine codes range from 90476 through 90749 with the additional range 91300-91303 added in 2021 to cover the new COVID-19 vaccines. Q-codes are reimbursed at reasonable cost to providers, and Medicare deductible and co-insurance amounts do not apply when the Q-codes are reported to Medicare.

Age-restricted vaccines

While many vaccines don’t have specific age requirements, others can be designated pediatric, adolescent or adult. As a result, it’s important for coders to confirm that the vaccine administered is appropriate for the patient’s age.

Code set administration

In most vaccine billing scenarios, practices will bill separately for the vaccine and the vaccine administration. Administration codes encompass three general categories:

• CPT® range 90471 — 90474 identifies vaccines without Counseling (over 18 years of age)
• CPT® range 90460 — 90461 identifies vaccines with Counseling (thru age 18)
• CPT® range 91300 — 91303 identifies COVID-19 vaccines
• HCPCS Codes G0008, G0009 and G0010 are specific to Medicare beneficiaries

State programs

Some physician practices participate in state-sponsored Vaccines for Children (VFC) programs. Because the state generally provides the practice with the vaccines, physicians may not charge beneficiaries for the vaccines and physicians are not separately reimbursed by Medicaid or commercial carriers.

However, providers may charge patients for the administration fee associated with providing the vaccine. For vaccines provided as part of the VFC program, the CPT® code range is 90476 — 90749, with modifier SL appended in the first reporting modifier field.

Route of administration

Ensuring the correct route of administration allows the coder to select the appropriate administration code. Most vaccines are given as injections and are reported using administration codes 90471 and 90472. But there are a few oral and intra-nasal vaccines that are reported using administration codes 90473 and 90474.

Initial vaccines

If one or more vaccines are administered during an encounter, it is necessary to specify an initial administration code first. Initial administration codes include:

• 90471: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial
• 90473: Immunization administration for intra-nasal or oral route, initial

Only one initial administration code is reported per encounter. If both injectable and oral/intra-nasal vaccines are performed during the same visit, providers should report 90471 as the initial administration code. Codes 90471 – 90472 have a slightly higher reimbursem*nt than oral/intra-nasal administration.

Subsequent vaccines

If more than one vaccine is administered on the same day, a second or third administration code is required to document the additional vaccines. All subsequent vaccine codes (90472 and 90474) are classified as add-on codes and must be reported with an initial administration code. The definitions for subsequent administration codes are:

• 90472: Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, each additional vaccine
• 90474: Immunization administration for intra-nasal or oral route, each additional vaccine

When three or more vaccines are performed during an encounter, units should be applied to the administration code for each additional vaccine of the same type (injectable or oral).

Here are some examples:

• Five injectable vaccines: report 90471 X1 unit (initial) and 90472 X4 units (subsequent)
• One intra-nasal and two oral vaccines: 90473 X1 unit (initial) and 90474 X2 units (subsequent)
• Four injectable vaccines and one oral vaccine: 90471 X1 unit (initial) and 90472 X3 units (subsequent) and 90474 X1 unit (subsequent)

Product Vaccine Examples

COVID-19 Vaccine Codes

In response to the COVID-19 pandemic, the FDA has approved vaccines by Pfizer (December 11, 2020) Moderna (December 18, 2020) and Johnson & Johnson (Janssen) (February 27, 2021) for use under an EUA. The AMA has also created CPT code set in the likelihood that the AstraZeneca and University of Oxford is granted EAU approval. The administration code will be reported based on whether it is the first or second dose.

Under the CARES Act, Medicare will provide beneficiaries COVID-19 vaccine administration with no cost-sharing to beneficiaries under Part B coverage. Initially, providers will not incur a cost for the drug because products will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. The Centers for Medicare & Medicaid Services (CMS) states it will establish COVID-19 drug product allowances, which will be based on reasonable costs (or, for physician offices, 95% of Average Wholesale Prices), later. Per the Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services section 67.2, providers should not bill for drugs received at no cost.

COVID-19 vaccine product codes

* Initially, providers will not incur a cost for the drug product as they will be distributed through government agencies. Providers should not bill for the drug when they receive it at no cost. CMS will update the payment allowance later.

COVID-19 Vaccine Administration Codes

Effective immediately after the FDA approves vaccinations with an Emergency Use Authorization, providers may report the COVID-19 administration code based on the type of vaccine and which dose is provided.

All providers participating in the CDC COVID-19 Vaccine Program:

• Must provide the vaccine at no cost to the individual (may also balance bill)
• Cannot charge an office visit (or other fees or services) if the individual received only the vaccine
• May not deny vaccine based on insurance coverage or out-of-network status

The Office of the Inspector General encourages reporting potential violations through its tip line 1-800-HHS-TIPS (1-800-447-8477) or website. The following chart shows the vaccine product code with the corresponding administration code(s).

COVID-19 Vaccine Administration Payment Rate Increase

CMS announced on March 15, 2021 that COVID-19 vaccine administration payment rates will increase to $40 each dose (geographically adjusted). The increased rates, which go into effect for dates of service on or after March 15, 2021, are expected to increase the number of vaccines administered daily by helping to establish new or expand current vaccination sites, hire additional staff, and provide community education.

Vaccine Administration in the Home

Effective June 8, 2021, Medicare will pay providers currently eligible to bill for COVID-19 vaccine administration (i.e., physicians, pharmacies, non-physician practitioners, and hospitals) an additional $35 per COVID-19 vaccine dose when provided in the patient’s home to a Medicare beneficiary who has is hard-to-reach or has difficulty leaving home. M0201 COVID-19 vaccine home administration may be reported with the COVID-19 administration code when the sole purpose of the healthcare home visit was to administer the vaccine. This add-on payment raises the total provider reimbursem*nt to approximately $75 (which amount includes the $40 reimbursem*nt for the specific vaccine administration.) When a provider administers the COVID-19 vaccine to multiple people in the same home during the same visit, the provider may report M0201 (COVID-19 vaccine home admin) only once but should report all COVID-19 vaccine dose-specific administration codes.

RHCs and FQHCs COVID-19 Vaccine Billing

Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) cannot bill COVID-19 for COVID-19 vaccines on a claim form. If the patient is there for another reason, the RHC or FQHC should exclude the cost of the vaccines. It will be settled on a cost report.

A listing of payment rates by each type of Medicare provider can be found in the Medicare FAQ link.

Additional Resources

• PARA Healthcare Analytics/ParaRev COVID-19 Coding Resource
• Novitas JH (Medicare MAC) provides billing information for Part B providers.
• First Coast Service Options (Medicare MAC), has a webpage devoted to billing for COVID-19 vaccines and monoclonal antibodies for Part A providers.
• CMS created a resource page to provide COVID-19 vaccine policies and guidance for providers, state programs, and beneficiaries.
• Additional information is available through the following CDC weblink.
• The AMA provides instructions for coding administration of the COVID-19 vaccines through its document.

Keeping it all straight

Staying abreast of the latest coding directives can be a challenge, and it can be doubly so when it comes to vaccines, given all the factors that need to be accounted for to code and bill correctly. That’s why Healthcare Financial Resources Inc. (HFRI) and PARA HealthCare Analytics have partnered to deliver comprehensive revenue cycle services to support accurate coding, clean claims and timely and appropriate reimbursem*nt. Contact us today to learn more about the many ways we can help your organization.

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