There a couple of confusing things about immunization coding as it relates to medical billing. First, there are different codes for the vaccine and the administration. That’s because some vaccines are provided by states for children, and the physician is paid only for the administration. Second, Medicare was not initially developed to provide preventive care, so it did not cover vaccines for many years. More recently, it began paying for a few preventive services such as flu shots, but it developed a separate set of codes.
Here are the correct codes to bill Medicare for immunizations today:
- 90460 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component
- 90461 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered
The above immunization codes have specific criteria as to the circumstances when they can be used for billing. It also requires a face-to-face service where providers counsel patients directly. 90460 is used for the primary component while the add-on code 90461 is used for each additional one.
- 90471 – Immunization administration
- 90472 – Immunization administration
- 90473 – Immunization administration by intranasal or oral route; one vaccine
- 90474 – Immunization administration by intranasal or oral route; each additional vaccine
The above immunization codes are for administrations in the absence of direct patient counseling.
1. For Medicare patients, use separate reporting guidelines and a different code set (G-codes). For example, G0008 – influenza, G0009 pneumococcal, G0010 – Hepatitis B
2. The route of the vaccine administration determines the right code. Although most are given as injections, there are a few intranasal and oral vaccines.
3. If giving multiple injections on a given day, one is reported as the initial administration with the appropriate code, and the others are classified as add-on codes.
4. Influenza, pneumonia, hepatitis B and flu H1N1 must be reported using G codes for all Medicare patients.
5. Medicare does cover immunizations that are directly related to an injury or exposure to a disease (i.e., tetanus, antivenin, immune globulin, and anti-rabies).
Tetanus shots that do not contain pertussis (whooping cough) are covered by (Medical Insurance) when you have been injured or directly exposed to material with tetanus
Who is Eligible?
All people with Medicare Part B are covered.
Your Costs in Original Medicare
If you get the shot from a doctor who does not accept assignment, you may have to pay an additional fee for the doctor’s services, but not for the shot itself. If you get the shot in a in a hospital outpatient setting, you pay a copayment.
Interestingly, unlike many codes, vaccinations do not get more complicated in ICD-10. Code Z23 is used to indicate any encounter for a vaccination. The procedure codes are used to identify the type of the immunization given and how it was administered. All Z codes must be accompanied by a corresponding procedure code.
Note that the guidelines state that Z23 can be used as a secondary code for patient visits that include an inoculation. Example:
Flu Shot as of Oct 2014 -ICD-10-CM: Z23 – Encounter for immunization
• ICD-10-CM code Z23: One comprehensive diagnosis code for any encounter for inoculations and vaccinations
• Code Z23 is for encounters for inoculations and vaccinations
• It means patient is being seen to receive a prophylactic inoculation against a disease
• Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit
• Must also report procedure code to identify the types of immunizations given